Disorders and Injuries of the Shoulder part 2 Flashcards
Clinical presentation of Humeral fractures
Severe pain
Limited ROM
Swelling
Ecchymosis (bruising)
What classification tool is used to assess humeral fractures?
Neers classification
Location, fracture parts and displacement
Most frequent cause of shoulder pain
Subacromial Impingement Syndrome (SAIS)
What is the pathology that creates a Subacromial impingement syndrome?
What structures are typically involved
Decreased subacromial space causes repetitive mircrotruama
- Supraspinatus tendon
- Subacromial bursa
- Long head tendon of bicep
What are the three types of Acromion morphology?
Type 1: Flat
Type 2: Curved
Type 3: Hooked
What affect does a Type 3 “Hooked” acromion have?
Decrease subacromial space
More contact with RC tendons
Increased risk of SAIS → increased risk of RC tear
What causes a Primary Impingement?
What age is this most common in and WHY?
Considered degenerative changes
> 35 y/o
Bone spurs &/or calcific deposits
“true” or “classic” impingement
What causes Secondary impingement?
Due to repetitive overhead movement
Abduction and ER
Who is a secondary impingement most common in and at what age?
<35 y/o
Overhead athlete
Faulty scapular posture
What contributary factors can cause secondary impingement?
Faulty scapular posture
- Forward head
- Increased thoracic kyphosis
- Leads to adaptive muscle imbalances
How does muscle imbalance cause secondary impingement?
Tight pec minor can cause anterior tilting & protraction
↓ subacromial space → impingement → inflammation and gradual degeneration of subacromial structures
What findings do you see during physical exam when assessing Secondary impingement?
Gradual onset of anterior and lateral shoulder pain (deltoid tuberosity) exacerbated by overhead activity
Night pain and difficulty sleeping on affected side
Tenderness to palpation over greater tuberosity, subacromial bursa and biceps tendon (long head)
What special diagnostic test can you perform during physical exam if you suspect subacromial impingement
Neers impingement
Hawkins impingement test
What strength test are used to assess subacromial impingement?
External rotation strength testing
Empty can testing
Lift off Subscapularis test
Which imaging test would you order order for someone with subacromial impingement?
Why and for what benefit
X-ray
Always in cases of traumatic injury to r/o fracture
Eval for calcifications / bone spurs
Evaluation of acromial morphology
What are initial treatments for subacromial impingement
NSAIDs and avoidance of offending activities
Modify sleeping position
Therapy program focusing on postural correction
-Physical therapy
-Home therapy
If initial treatment does not help someone with subacromial impingment what other treatment is next?
subacromial corticosteroid injection
What is subacromial decompression surgery recommended?
Failure of conservative care (NSAIDS,injection,physical thearpy
Evidence of calcification and bone spurs
What is the MC etiology for a Rotator Cuff injury
Overuse MC
Others:
Age-related degeneration
Chronic mechanical impingement
Traumatic
Which tendon do rotator cuff injuries MC originate from?
Supraspinatus tendon (90%)
Clinical Presentation of a Rotator Cuff injury?
Recurrent shoulder pain for several months (overuse)
Specific injury that triggered the onset of the pain (traumatic)
Subacromial pain and pain localized to deltoid tuberosity
Night pain and difficulty sleeping on affected side
Weakness, catching, and grating especially when lifting the arm overhead
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Gold Standard imaging to diagnose Rotator cuff tear?
What must be ordered alongside with a partial tear?
MRI
If chronic injury and concern is for partial tear order arthrogram
What imaging usually has to get order prior to ordering MRI?
What does it look for?
X-ray
Traumatic injuries to r/o fracture
Eval for calcifications / bone spurs
What are non-surgical treatment options for rotator cuff injuries?
What kind of tear are these best used for?
NSAIDs, PT, and avoidance of overhead activities Steroid injection (should never receive > 3 subacromial injections/year)
When is surgery warranted for a rotator cuff injury
Patient with significant symptoms and failed rehab > 3-6 months
Patient with acute TRAUMATIC cuff tear can receive what kind of treatment? How soon?
Surgery
Best done acutely or no later than within 6 weeks of injury
What is Adhesive Capsulitis? (Frozen shoulder)
What age group is this found in?
What is the most common risk factor?
Idiopathic loss of both active and passive motion
Most commonly affects patients 40-60 years of age
DM (esp. type 1) is most common risk factor
How does Adhesive Capsulitis occur?
Inflammatory process involving the glenohumeral capsule
What is the most pronounced range of motion loss with Adhesive Capsulitis?
What are other losses
External rotation –> MC
Abduction
Flexion
What kind of pain is seen with Adhesive Capsulitis?
Dull / achy at rest (deltoid tuberosity)
Sharp at end range of restricted movements (GH joint)
What imaging is used to confirm suspicion of Adhesive Capsulitis?
MRI
Radiographs help rule out other pathologies though
What is the “Freezing” phase seen in Adhesive Capsulitis?
Freezing” phase - pain and progressive loss of motion
What is the Thawing phase?
“Thawing” phase - decreasing discomfort associated with a slow but steady improvement in ROM
What are initial treatment options for Adhesive capsulitis?
Intra-articular injection of steroid may be considered
Physical Therapy
What is recommended when treating Adhesive capsulitis with PHysical therapy?
Pain prescriptions prior to therapy
When is surgery warranted for adhesive capsulitis?
after 9-12 months of failed initial treatment
