D/Os of Shoulder & Neck Flashcards
Diagnostics of acute muscle spasm or strain of the neck?
XR = lateral cervical spine to include C7
- -r/o Fx (acute).
- -Loss of cervical lordosis (chronic).
Injury to the muscles and/or ligaments surrounding the cervical spine?
Acute muscle spasm or strain.
HPI of acute muscle spasm or strain?
*Hyperextension injury, “WHIPLASH.”
“Delayed” onset of Sx:
–Stiffness, Pain, Difficulty w/ROM, HAs, Muscle tightness.
What should always be included in a physical exam of neck injuries or all orthopedic injuries?
- Inspection.
- Palpation.
- ACTIVE ROM (AROM) before Passive.
- Strength.
- Special tests.
- Neurovascular exam.
Characteristics of the PE in acute muscle spasm or strain?
- Inspection = ridged appearance.
- Palpation = tenderness over musculature, esp. SCM/upper trapezius.
- AROM = “painful extension,” limited flexion, extension, lateral bending or rotation.
- Strength = pain against resistance.
- Special tests = none.
- Neurovascular = normal.
Where do 90% of disc lesions occur?
At C5-C6 levels
“Compression” test for cervical disc disease?
Push down on the skull of the seated patient. If pain from neural foramen stenosis exists, then this movement will cause neck or extremity pain.
**This should be a gentle maneuver and does not come completely w/o risk of liability.
Diagnostic tests for Cervical Disc Disease?
- XR – AP, Lateral Cervical spine (will not always show anything but indicated for insurance purposes to get and MRI).
- -loss of disc height w/spinal stenosis.
- -osteophyte formation.
- -narrowing of the intervertebral foramen. - **MRI - Gold Standard.
- -Disc herniation, nerve root compression. - EMG/Nerve Conduction Study:
- -evaluates peripheral nerves.
- -may need to refer before completing this test.
Treatment for cervical disc disease?
- NSAIDs (check pt history - CV, GI).
- Analgesics (Tylenol).
- PT.
- Chiropractic therapy.
- Referral to neurology or neurosurgery.
- Most will improve with time.
- Approx. 5% will need surgery*
Name all the rotator cuff muscles:
“SITS”
- Supraspinatus.
- Infraspinatus.
- Teres Minor.
- Subscapularis.
“Chronic Inflammation” of the rotator cuff at the musculotendinous junction, which creates scarring and thickening of the rotator cuff?
Tendinitis of the shoulder.
Inflammation of the “Subacromial Bursa?”
Bursitis of the subacromial bursa.
Soft tissues structures “pinched” between the humerus and the arch of the “acromion?”
Impingement of the shoulder rotator cuff muscles.
–poor functioning rotator cuff causes humoral head elevation toward the arch of the acromion.
Diagnostics of Tendinitis - Bursitis - Impingement?
- XR – AP, Lateral/Scapular Y, Axillary.
- -Scapular Y view assists w/evaluating the angle of the acromion.
- -Axillary view provides visualization of the glenoid and glenohumeral joint.
A partial or complete tear of the rotator cuff?
Rotator Cuff Tears.
Which “SITS” muscle is most commonly involved in a rotator cuff tear?
Supraspinatus.
- Rare to see teres minor involved.
- May occur suddenly w/trauma or gradually.
Possible HPI of a rotator cuff tear?
- Fall.
- Traction injury.
- Lifting a heavy object.
- Proximal lateral arm pain.
- “Weakness” w/flexion, abduction.
- Throwing athletes, intensive laborers.
Treatment for Rotator Cuff Tears?
- NSAIDs.
- Analgesics.
- ICE.
- Local steroid injection.
- PT (esp, if surgery.)
- Consultation to “Orthopedic Surgeon.”
- –esp, if traumatic MOI.
What is Adhesive Capsulitis also known as?
“Frozen Shoulder Syndrome.”
Diagnostics for Adhesive Capsulitis?
**Diagnosis is Clinical!
-XR: AP, Lateral/Scapular Y, Axillary
(pt may not be able to perform an axillary view due to decreased ROM).
Treatment for Adhesive Capsulitis?
- NSAIDs, analgesics, ICE/Heat alternation.
- Local Steroid injection.
- **PT – aggressive range of motion.
- Consult to Ortho Surgeon for possibly manipulation under anesthesia.
- CPM chair (Continuous Passive Motion).
What is the approx. time for recovery from adhesive capsulitis?
Approx. 6 months or more to recover.
**Early recognition and prevention is key!”
An accumulation of scar tissue in the joint capsule?
Adhesive Capsulitis
What are the 3 stages of Adhesive Capsulitis?
- Painful – freezing.
- Adhesive – frozen.
- Recovery – thawed.
Adhesive capsulitis causes?
Primarily “Idiopathic;” 2dry can be from injury or shoulder surgery.
Who is adhesive capsulitis more common in?
MC in women, DM pt’s, Thyroid disease.
5th decade of life most common.
HPI of Adhesive Capsulitis?
- -Gradual onset of pain.
- -Proximal lateral arm pain.
- *Stiffness and decreased ROM.**
- -Trouble laying on arm.
- -Locking of the arm.
Most will complain that their are is frozen and they can’t move it.
PE of Adhesive Capsulitis?
- Inspection: holding arm at side.
- Palpation: generalized tenderness.
- AROM:
- -Decreased flexion, abduction and external rotation; most will still be able to internally rotate.
* *Passive ROM decreased.** - Strength: can be difficult to test due to stiffness.
- Special Tests: can be difficult to test due to stiffness.
- Neurovascular: normal.
Disruption of the glenohumeral joint where the humerus translates anteriorly or posteriorly in relationship to the glenoid?
Shoulder dislocation
**90% are anterior. Posterior is rare.
HPI of shoulder dislocation?
Anterior: “Forceful abduction and external rotation”.
Posterior: occur w/seizures, or a force applied to an internally rotated arm.
Anterior dislocation mnemonic?
TUBS:
- Traumatic injury.
- Unilateral injury.
- Bankart labral tear or Hill-Sachs Glenohumeral Fx.
- Surgical mgmt, often necessary.
Posterior Dislocation mnemonic?
AMBR:
- Atraumatic.
- Multidirectional instability present prior.
- Bilateral or Hx of bilateral instability.
- Rehab recommended for treatment.
PE of Anterior Dislocation?
- Inspection = arm adducted and in external rotation.
- Palpation = prominent acromion, “palpable divot” where humeral head should be.
- AROM = minimal and painful, “internal rotation is painful.”
- Strength = decreased.
- Special tests:
“Apprehension,” Sulcus, Dugas.
–special tests are not for acute dislocations; mostly to eval for return to play or recovery. - Neurovascular:
“eval and document NV status pre- and post-reduction.
PE of Posterior Dislocation?
- Inspection = “arm is in internal rotation” w/forearm on abdomen.
- Palpation = prominent acromion.
- AROM = minimal and painful, “external rotation is painful.”
- Strength = decreased.
- Special tests = Sulcus.
- Neurovascular:
“Eval and document NV status pre- and post-reduction.”
Diagnostics for Shoulder dislocation?
- XR – AP, Lateral/Scapular Y, Axillary, Posterior Oblique.
“Post reduction XR is a must!”
-Posterior Oblique = good for posterior dislocation as it gives view of glenohumeral joint.
When is an MRI indicated in shoulder dislocation?
If the pt has not fully healed in 4-6 weeks and cont’d pain.
Treatment of Shoulder dislocation?
- Reduction:
–good muscle relaxation is a must (IV sedation).
“Gentle Straight Traction”
“Stimson Traction Method”
“Risk of causing further damage incl. humeral head Fx.” - NSAIDs, Analgesic, ICE, Sling for 1-2 wks.
- Begin gentle ROM as Sx improve.
- PT.
- “Avoid positions that might cause a dislocation.”
- Pt’s under 30 yrs old have a 50% chance of 2nd dislocation.
- Multiple dislocations = surgery.
The cartilage that lines the glenoid providing stability to the shoulder joint?
Labrum
SLAP Tears?
Injury to the labrum.
SLAP = Superior labrum anterior and posterior.
HPI of a Labral Tears?
- Sudden trauma (MVA, traction injury).
- Overhead throwers.
- Wrestlers.
- Aging.
- *Instability, clicking, poppin, boring pain.
PE of a Labral Tears?
- Inspection = may notice elevation at SC joint.
- Palpation = crepitation w/ROM, tenderness along anterior joint line.
- AROM = full.
- Strength = full or loss.
- Special tests = Obrien’s, Speeds, Clunk.
- NV = normal.
Diagnostics for a Labral Tear?
- XR - AP, Lateral/Scapular Y, Axillary.
2. MRI w/Arthrogram.
Treatment for a Labral Tear?
- NSAIDs, analgesics, ICE.
- Glenohumeral steroid injections (fluoroscopy guidance).
- PT.
- Surgery:
- -Labral repair.
- -Younger pt’s.
- -Instability.
Labral Repair recovery and risks?
- Repair – sutures and anchors.
- Recovery:
- -sling use for 6 wks.
- -Formal PT.
- -Return to activity = 6 months. - Risks = infections, failure of sutures or anchors, limited ROM, damage to cartilage.
What disorder causes disruption of the glenohumeral joint articular cartilage?
Glenohumeral Osteoarthritis
- progressive vs. post-traumatic.
- mild, moderate, severe.
HPI of Glenohumeral Osteoarthritis?
- -Chronic shoulder instability.
- -Handedness.
- -Repetitive activity.
- -Pain, crepitation, decreased ROM.
PE of Glenohumeral Osteoarthritis?
- Inspection = possible joint effusion.
- Palpation = crepitation w/ROM.
- AROM = decreased.
- Strength = decreased w/rotator cuff disease.
- Special tests = none.
- Neurovascular = normal.
Diagnostics for Glenohumeral Osteoarthritis?
- XR – AP, Lateral/Scapular Y, Axillary.
- osteophytes, joint space narrowing, etc.
Treatment of Glenohumeral Osteoarthritis?
- NSAIDs, analgesics, ICE.
- Glenohumeral steroid injection (fluoroscopy guidance).
- PT.
- Surgery
- -Total Shoulder Arthroplasty (intact rotator cuff).
- -Reverse Total Shoulder Arthroplasty (torn rotator cuff that is irreparable).
Shoulder repair, recovery and risks?
- Total or Reverse Total Shoulder Arthroplasty using metal and plastic implants w/cement.
- Recovery:
- -Sling use for 6 wks, w/home exercises as tolerated.
- -Formal PT after 4-6 wks.
- -Return to activity = 3 months. - Risks:
- -infection, failure of hardware, failure of subscapularis repair w/total shoulder, limited ROM/strength.
Treatment for an acute muscle spasm or strain?
- Rest, NSAIDs, analgesics.
- Soft cervical collar, 1-2 wks.
- Ice (acute). Heat (chronic).
- PT.
- Chiropractic Treatment.
What two disorders are within the cervical disc disease category?
- Cervical Disc Protrusion.
- Spinal Stenosis.
**presentation, diagnosis and treatment are very similar.
“Herniation” of the nucleus pulposus outward?
Cervical Disc Protrusion.
“Narrowing” and collapse of the disc space?
Spinal Stenosis.
Characteristics of Cervical Disc Protrusion vs Spinal Stenosis?
Cervical disc protrusion:
“younger” pt’s.
“immediate (acute)” or gradual compression of the nerve root.
Spinal Stenosis:
“older” pt’s.
“gradual” compression of the nerve root.
–vertebrae become closer, bone spurs form, decreased size of the intervertebral foramen.
Important to remember about nerve roots…
In the cervical spine, the nerve roots exit ABOVE the vertebrae they are numbered for.
Thoracic and down exit below.
HPI of cervical disc disease?
- “Radicular Symptoms,” following a dermatome pattern.
- Neck stiffness.
- Painful extension.
- Worse w/coughing, sneezing, valsalva.
- “Numbness and Tingling” (ants crawling, pins/needles).
- “Unilateral” Sx.
- Referred pain along the medial border of the scapula.
PE of Cervical disc disease?
- Inspection = neck guarding.
- Palpation:
- -tenderness over cervical spinous processes.
- -trigger points along rhomboids. - AROM = decreased, pain w/extension.
- Strength = weakness upper extremities.
- Special tests:
- - “Compression (Spurling),” Jackson’s compression, valsalva maneuver. - Neurovascular = “decreased sensation” in dermatomes; reflex changes.
Compression of the cervical spinal cord will produce PE findings where?
Lower extremities.
Symptoms of a disc lesion at C5-C6?
- Pain location = neck, medial scapula, lateral arm, shoulder, dorsal forearm.
- Sensory Deficit = lateral forearm, thumb and index finger.
- Motor weakness = biceps and wrist extension.
- Reflex deficit = biceps, brachioradialis.
**see slide 11 on ppt.
What to keep in mind when evaluating the shoulder?
- Repetitive motions.
- Age and integrity of the rotator cuff tendons.
- Shoulder instability overloads the rotator cuff.
- Downward sloping acromion.
HPI of Tendinitis - Bursitis - Impingement?
- Pain:
- -at night.
- -with “overhead activity,” esp. with “abduction.”
- -reaching behind the back. - Proximal lateral arm pain (referred pain to the deltoid).
- Trouble laying on the shoulder.
PE of Tendinitis - Bursitis - Impingement?
- Inspection = pt grasping lateral arm.
- Palpation:
- -tenderness lateral to the acromion at the greater tuberosity, upper traps, posterior musculature.
- -crepitation w/ROM. - AROM:
- - “pain w/ABDuction,” esp. from 60-120 degrees.
- -pain w/forward elevation, internal rotation.
- -passive ROM painful. - Strength = minimal loss.
- Special Tests = “impingement, Hawkin’s”
- Neurovascular = normal.
What are the Impingement and Hawkins Tests?
To test for AC impingement.
Impingement = AC joint impingement of the supraspinatus tendon. Involves passive forward flexion of greater than 90 degrees; + test is AC joint pain.
Hawkin’s = AC joint impingement and supraspinatus tendon weakness/tear. Same as impingement but thumb is pronated.
Treatment for Tendinitis - Bursistis - Impingement?
- AVOID overhead activity.
- NSAIDs, analgesics, ICE.
- “Local Steroid Injection”
- -into subacromial space.
- -1-2cc of steroid combined w/2-4cc of local anesthetic.
- -Safe to give every 3-4 months. - PT.
PE for rotator cuff tears?
- Inspection = pt grasping lateral arm, “deltoid assistance.”
- Palpation = tenderness to acromion at greater tuberosity, upper traps and post. musculature; crepitation w/ROM.
- AROM = may be full, “usually decreased” w/abduction, flexion. PROM usually pain free.
- Strength = “loss of strength” w/abduction, flexion, internal rotation.
- Special tests = impingement, hawkin’s, “Jobe’s (empty beer can) and Drop arm,” lift-off.
- Neurovascular = normal.
What is the Jobe’s Test, Drop Arm test, Lift-off test?
Jobe’s Test aka “Empty Beer Can Test”
–a test for relative isolation of the supraspinatus.
Drop Arm test:
- -fully abduct arm and then slowly lower it. A positive test is sudden drop of the arm to the side.
- -Pain or weakness indicates painful arc syndrome (bursitis, rotator cuff strain, tendonitis, impingement).
- -Inability to maintain a 90 degree abduction position against gravity (less than +3/5 muscle strength) indicates severe injury (grade 3 cuff tear).
Lift-off test:
–the pt reaches behind the back for the scapula (indicates anterior capsule ROM). Ability to lift the hand off the back indicates an intact subscapularis.
Diagnostics for Rotator Cuff Tears?
- XR – AP, Lateral/Scapular Y, Axillary.
- -may notice “humeral head elevation” towards the acromion.
- -calcific deposits.
- -cystic changes in the humeral head. - “MRI prefered w/Arthrogram.”
- Ultrasound.
