Intro/Shoulder Flashcards
Why do most MSK patients come to us for help
Pain
How do we begin to help a patient with their pain?
1 Very thorough subjective examination
2 Planning an objective exam
3 Based on info gathered, employ detailed exam with the goal of reproducing your patient’s complaints of pain
Why would we not be able reproduce the patients pain (the pain that they are coming to see us for)?
1 They may not have a MSK problem
2 We may be missing something
3 We need to know when it is time to refer them to another physician
What gives clues as to if the symptoms are mechanical or inflammatory?
The behavior of symptoms in response to activity and rest
For the subjective exam, we establish SIN which is?
S: Severity - severe symptoms make holding a position difficult
I: Irritability - a small amount of activity provokes symptoms, and they last
N: Nature - mechanical vs. inflammatory
In order to ensure safety of the patient you must first know ?
Must know how far they can go so that we do not push them too hard
MSK is mostly?
Mechanical
What are the 5 categories that the subjective exam is divided into?
Kind of disorder
Site and nature of symptoms
Behavior of symptoms
Special questions
History
When asking a patient about their pain should you ..
1 keep it general/ vague
2 ask specific questions
and why?
example?
After you establish the disorder you are dealing with, you should ask the patient …?
1 keep it vague
you will get more information if you ask general questions in an open way and let the patient speak
for example: “what brings you in to see us” “what do you think your main problem is”
What is their goal, what would they like to be able to do that they cannot at the time of the evaluation
Using a body chart is recommended in order to help find
It is very important to know specifically where the ___ is coming from on the patient
site and nature of symptoms
pain
In regards to pain….
1 a constant ache indicates?
2 acute nerve pain is more likely to be?
3 somatic referred pain is more likely to be?
4 chronic nerve pain is more likely to be?
5 catching pains may indicate?
1 inflammation or venous congestion
2 sharp, burning, or shooting
3 deep, dull, and aching
4 aching in quantity
5 fragment in a joint
In regards to unvarying or constant pain what should be done
Everything that you as a therapist can do, but if it cannot be treated it may not be a MSK problem so they should be referred
You should always aim to establish a patients ___
SIN
Mechanical pain symptoms can usually be relieved or eliminated by?
But inflammatory pain in nature cannot always be relieved by? What are characterized by?
When inquiring about a patients pain in regards to rest and intensity what should be asked? (3)
Why does mechanical pain get worse at the end of the day?
A position or movement
Rest, they are characterized by soreness or stiffness lasting longer than 1/2 - 1 hour after a prolonged rest period
What reproduces your pain and can you relieve it? Can you find a comfortable position to sleep in at night? - What makes your pain worse? Is the pain constant?
Overuse during the day
Compare and contrast chemical vs mechanical pain
Morning or nocturnal?
When does pain occur?
Does rest relieve it?
Duration of morning stiffness?
Chemical: constant or continuous nocturnal, pain is unaffected by rest, night pain may disturb sleep, morning stiffness lasting longer than 2 hours
Mechanical: intermittent, eased by rest, can sleep without waking from pain, morning stiffness lasting less than a few minutes and relieved with appropriate activity
What are a few general health questions that should be asked (special questions category or subjective exam)? (3)
1 How is your general health (heart/lung issues, recent surgeries)?
2 Any recent weight loss (>5% BW in 4 weeks is considered significant)
3 Are you taking any medication (blood thinners, prolonged steroid use, dizziness is a common side effect)
For history (category of subjective exam) what should be asked?
We should inquire about if they have been treated for this before and if so ….
When and how did the current episode begin - if it is specific find out the position at the time of injury and the magnitude of force
Ask what worked/what didn’t/ if the treatment was successful, must be very specific
Possible cauda equina issues
Bowel or bladder problems
Saddle area tingling
Sexual dysfunction
Severe bilateral sciatic pain
Innert vs Contractile tissues
Innert: joint capsules, bursae, ligaments
Contractile: muscle-bone attachments, muscle belly, body of tendon
For non contractile tissues AROM, and PROM are painful the ____ direction
Where does pain usually occur
For contractile tissues PROM and AROM are in ____ direction
same
end range
opposite (because it is being stretched)
Normal end feels for elbow and knee
bone to bone
capsular
soft
abrupt stop (elbow extension)
abrupt stop (hip rotation)
Interpreting resisted testing results:
strong and painless
strong and painful
weak and painless
weak and painful
all painless
all painful
-working nerve or muscle
-working nerve or “minor” muscle problem/tendon
-potential nerve lesion and/or “old” complete muscle rupture (nervous system disorder)
-potential nerve lesion and/or significant muscle tear - gross lesion
-no contractile lesion
-very low threshold or FOS (:
physiologic movements
vs
accessory movements
plane movements (external rotation)
vs
2 joints moving on each other (patient cannot do it themselves)
most common dislocated major joint in the shoulder
ultimate key to pain free function
where is the greatest bony congruity/ what are the other stabilizers of this joint
glenohumeral joint
functional glenohumeral stability
between 60 and 120 degrees, glenoid labrum, shoulder capsule
Compression by the _________ and ________ can help stabilize the humeral head in the absence of a supraspinatus IF the glenoid cavity is intact
infraspinatus and subscapularis
What works with serratus to upwardly rotate the scapula
What downwardly rotates it
upper middle and lower trapezius
pec minor, rhomboids, levator
Muscles for internal rotation
Muscles for external rotation
- subscap, pec major, latt, teres major
- infrasp, teres minor, post delt
Does the area of the pain tell us anything
no
Proximal stability before
distal mobility
GIRD
commonly seen in
proposed cause of tight posterior capsule/GIRD in throwers
glenohumeral internal rotation deficit
overhead athletes
repetitive tensile load on capsule with follow through, forces aren’t controlled by stabilizers, capsule hypertrophies in response
Scapular dyskinesis
the set of abnormal scapular motions and positions
SICK Scapula
potential test?
Scapular malposition
Inferior medial border prominence
Coracoid pain and malposition
Dyskinesis of scapular movement
dropped shoulder
Causes of scapular dyskinesis (6)
-lack of protraction (increases deceleration forces on the cuff)
-too much protraction (GH capsular tightness, weakness in rotractors)
-lack of appropriate acromial elevation (impingement of cuff)
-loss of coordinated retraction/protraction
-lack of full retraction
-unstable scap in general (cervical pain)
The 2 categories of shoulder instability
AMBRI
TUBS
atraumatic
multidirectional
bilateral
rehab
indicated
traumatic
unidirectional
bankart injury
surgery indicated
Adhesive capsulitis/Frozen shoulder
stages (3)
- classic loss of ROM in all directions
- Freezing: deltoid (eventually severe pain at night)
- Frozen: pain primarily at end range only )eventually minimal pain with stiffness)
- Thawing: gradual improvement of motion
- ^ all progress from 12-18 months (freezing - thawing)
TERT
total end range time
Resisted tests for scapula (6)
ER at 0 abd
Ir at 0 abd
Flexion at 90 abd
ABD at 90 ABD
Scaption at 90 ABD
ER/IR at 90/90 position (possibly)
Scapular tests (3)
Wall push ups for winging (5-10)
Kibler’s lateral slide test (3 positions)
Scapular assistance test
Types of end feels
bone on bone
spasm
capsular
springy block
tissue approximation
empyt
1 Pain before resistance -
2 Pain synchronous with resistance -
3 Resistance before pain -
1 active lesion, extra articular lesion - no stretching
2 capsular feel gentle/moderate stretching (grade 1 or 2)
3 strong stretching (grade 3 or 4)
For capsular patterns of the GH joint what are the movements most limited in order
which is more restricted anterior or posterior or inferior
most important movements
ER>ABD>IR
ant>inf>post
hand behind back, IR, ER, ABD
SAIS impingement syndrom aka
causes?
The 4 acromial shapes
bursal side impingement
1 acromial shapes
2 humeral head depression
3 scapular rotator/ stabilizer weakness
4 posterior shoulder tightness
5 GH instability
1 flat
2 increased angel
3 curved
4 hooked
Can patients do accessory movements?
No, we as PTs do them
Reverse capsular pattern
reverse of the normal pattern
During abd of the arm where does it hurt the most in a patient with an injury
Strategies for impingement patients
When the arm is lifted above 90 degress or shoulder level referring to shoulder impingement syndrome
posterior shoulder stretching, scapular stabilization, pec/min/major stretching, levator scap strecth, RTC strengthening, possible biceps
During internal impingement what 2 movements occur?
What is the cuff pinched between?
What is typically limited?
The GH joint is inherently _______?
external rotation and abd
labrum and greater tuberosity
hand behind back, sleeper stretch, and IR/ER
unstable
laxity
vs
instability
generally
laxity
vs
instability
in regards to shoulder
loseness of limb or muscle/ amount of motion you have
when a motion turns into a painful condition
the ability of the humeral head to be passively translated on the glenoid fossa
clinical condition in which unwanted translation of the humeral head comprises the comfort and function of the shoulder
Spectrum of instability
overhead athletes usually start out in the _____ of the spectrum
as they shift to the right there is an increased dependency on the (2)
RTC muscles
TUBS (torn loose) ——> AMBRI (born loose)
middle
RTC, scapular stabilizers
subscaplularis, infraspinatus, supraspinatus, teres minor
In regards to supraspinatus what is empty can and what does it increase?
what does it decrease?
what should be used instead of empty can?
which exercise is NOT appropriate early on?
thumb facing down as if you are pouring out a can, increases scapular internal rotation and anterior tilting
subacromial space
full can
wall walks
Strong depressors in the RTC muscles
The 3 functions of the RTC muscles
manual test for RTC are only accurate if there is a > __ % deficit
infraspinatus and teres minor (they act together to stabilize the joint)
subscapularis
dynamic stabilization
fine tuner
movement
20
3 tests for the RTC
When adding a new exercise what do you need to know regarding what is safe?
drop arm
painful arm
pain or weakness with ER
when the strength of the surgery is SIGNIFICANTLY greater than the STRESS THE EXERCISE PUTS ON THE REPAIR
Mechanisms of injury (what actions does each include and how)
ANT sublux/dislocation -
POST ^ -
MDI (multidirectional shoulder instability) -
- ABD, ER, Horizontal ABD and sometimes ext (tackle)
- FLEX, horizontal ADD, IR, direct blow (MVA)
- usually born with or trauma with signif INF translation
Hill Sachs lesion involves
Reverse Hill Sachs lesion
With throwers, surgery should be avoided but if it is needed when should it happen?
When is surgery desirable?
- posteriolateral fx of the humeral head (associated with ANT dislocations)
- ANT fx of the humeral head (less common, seen with posterior dislocations)
- 3-6 months of appropriate physical therapy
- recurrent instability, end of session, when pt cant afford recurrence bc of job or etc.
Bankart repair
SLAP tears
surgical technique for repair of recurrent shoulder joint dislocation
superior labral anterior posterior
Functions of labrum
Injuries to the labrum occur during which 2 phases in throwers
increases depth of glenoid by 50%, acts like a seal or gasket
cocking phase or acceleration phase or follow through phase
Pre-Slap Syndrome and shoulder at risk examples
- complains of tightness in POST shoulder
- they cannot get loose
- usually GIRD or SICK
Nam and Synder Slap Classifications
Type 1-4
Type 5,8,&9 Slap classification
Type 1: fraying and edge
2: detached biceps anchor with fraying
3: bucket handle tear
4: splitting of superior labrum that continues into bicep tendon
8: anteroinferior labral detachment (BANKART)
9: posteroinferior labral detachment (POSTERIOR BANKART)
10: Firestone lesion (360 degree detachment)
OA is more common in the AC or GH joint?
Ways to help AC joint (5)
Grading of AC seperation (3)
AC
- scapular reatractors
- increase GH, SC, and TH mobility
- Pec minor/ major stretching
- stretch post shoulder
- manual disctractions
- some widening of the joint
- rupture of AC ligaments (subluxation)
- no contact between clavicle and acromion (dislocation)
Overuse injury is almost exclusively seen in youth baseball pitchers because of _____ _____ seperation
growth plate
X rays are good for seeing ?
Bone issues
