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PHTY3120 > L13: Skills Shoulder Case Studies > Flashcards

L13: Skills Shoulder Case Studies Flashcards

1
Q

What is the diagnosis? What is the moral of the story for diagnosis?

A
  • Full ROM
  • No adhesve capsulitis
  • No OA
  • Unlikely to be instability
  • No ACK (EOR without symptoms)
  • Full PROM
  • Can’t lift arm
  • 3 weeks ago
  • First symptom (sore neck) –> lost range
  • Traumatic? –> no fall

Older lady in 70s

  • Rotator cuff pathology
  • Acute C5 radiculopathy (weakness of muscles) –> muscle loss
  • Less GHJ
  • Movement at scapulothoracic
  • Careful
  • Don’t treat shoulder, rather treat radiculopathy
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2
Q

What is the source of scapular dyskinesis?

A

Scapular dyskinesis

  • Inferior winging
  • Anteriorly tilted
  • Muscle wasting

Pushing

  • Adducted scapular
  • Serratus anterior
  • Some medial border winging

Dengue fever

  • Long thoracic nerve pathology
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3
Q

Patient 1

  • 25 yo male
  • Office worker / social rugby
  • Tackled on W/E
  • Landed on shoulder
  • Immediate pain
  • Limited AROM by pain
  • Limited PROM by pain

What is the 3 differential diagnosis?

A
  • ACJ
  • Consider fracture
  • Exclude cuff injury
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4
Q

Patient 1

  • 25 yo male
  • Office worker / social rugby
  • Tackled on W/E
  • Landed on shoulder
  • Immediate pain
  • Limited AROM by pain
  • Limited PROM by pain

What is the 3 symptoms of ACJ?

A
  1. Localised pain and tenderness to palp
  2. Swelling
  3. Step deformity
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5
Q

Patient 1

  • 25 yo male
  • Office worker / social rugby
  • Tackled on W/E
  • Landed on shoulder
  • Immediate pain
  • Limited AROM by pain
  • Limited PROM by pain

What is the 2 symptoms of fractures?

A
  1. Palpate clavicle is pain localised
  2. (probable imaging)- Rule out/in distal clavicle fracture
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6
Q

Patient 1

  • 25 yo male
  • Office worker / social rugby
  • Tackled on W/E
  • Landed on shoulder
  • Immediate pain
  • Limited AROM by pain
  • Limited PROM by pain

What is a symptom of cuff injury?

A

Time and response as acute pain settles

Not at lateral shoulder

Superior on ACJ

Can exert moderate amount of force

PROM (no range)

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7
Q

What are 9 treatments for ACJ injury (limited pathology based)?

A
  1. Inflammatory- RICE and sling (support shoulder)
  2. Pain- Manual therapy (caudal glide –> afferent input at ACJ)
  3. Regain ROM- Relative to pathology
  4. Muscle optimisation
    • Control scapula-Loss structural stability
    • Strength shoulder complex
  5. RICE / MICE- Can help with tissue healing
  6. Advice sleeping / positons of comfort
  7. Sling for comfort if grade 3 / maybe helps with grade 2 (couple of wks)- 3 months to lie on affected side
  8. –> ACJ caud III in neutral and progress toward provocative positions
  9. Motor control and strength
  10. Function
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8
Q

Patient 2

  • Patient 65 yo male
  • Golden oldies rugby
  • Slipped and FOOSH 2/52
  • Acute pain in region of body chart
  • Now easing but still limited AROM – difficulty with lifting, washing under arm, dressing
  • Otherwise well
  • AROM 700 elevation
  • PROM 1600 not particularly pain

What are 8 things to rule out?

A
  1. Not superior = not ACJ
  2. OA of GHJ (uncommon) but could be possible
  3. Not instability (younger)
  4. Rotator cuff –> possible
  5. Trauma
  6. Pain on lateral and anterior shoulder (not superior = not ACJ)
  7. Not instability (younger)
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9
Q

Patient 2

  • Patient 65 yo male
  • Golden oldies rugby
  • Slipped and FOOSH 2/52
  • Acute pain in region of body chart
  • Now easing but still limited AROM – difficulty with lifting, washing under arm, dressing
  • Otherwise well
  • AROM 700 elevation
  • PROM 1600 not particularly pain

What are 4 differential diagnosis?

A
  1. Possible massive cuff tear- Traumatic injury (hallmark)
  2. More mild tear and pain inhibition- Not as much as traumatic
  3. Fracture (impacted HOH)- Stable fracture but distorted structure of bone
  4. ACJ- Not likely
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10
Q

Patient 2

  • Patient 65 yo male
  • Golden oldies rugby
  • Slipped and FOOSH 2/52
  • Acute pain in region of body chart
  • Now easing but still limited AROM – difficulty with lifting, washing under arm, dressing
  • Otherwise well
  • AROM 700 elevation
  • PROM 1600 not particularly pain

What are 4 tests for the 4 differential diagnosis?

A
  1. Cuff integrity tests
  2. Cuff impingement tests
  3. Imaging USS +/- xray- Convenience
  4. Palpation of ACJ

Isometric/strength/ belly press/ lift off (IR/ER)

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11
Q

What are 12 treatments for acute cuff tear?

A
  1. Massive and acute cuff tear with significant physical disability
  2. Pain
  3. ROM
  4. Motor
    • Strength
    • Scapula dynamics if relevant
  5. Other impairments
    • Tight / stiff
  6. USS
  7. Surgical consult quite likely
  8. Maintain PROM as comfortable
    • Does not heal / no restrictions with pathology
  9. Manual therapy for pain if rqd
  10. Stiff / tight: Manual therapy and soft tissue stretches
  11. Progressive cuff strengthening program (what remains)
    • Isometric holds (in neutral) –> yellow band —> progress –> black band –> different positions/ranges –> functional
  12. Program of substitution lats for HOH depressor with activation of deltoid

90˚ = functional needs are sufficient? –> most it is not

Minority –> surgery

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12
Q

Patient 3

  • 20 yo. A grade cricket player – outfield
  • Dominant arm
  • Progressive restriction with throwing with discomfort- Pain in EOR
  • AROM pain EOR elevation
  • Increased with o/p- Overpressure (PROM)
  • Fit
  • Perhaps inferior angle of scapula winging

What are 7 differential diagnosis?

A
  1. Possible rotator cuff tendinopathy
  2. Small P/T or F/T tear
  3. Labral injury
  4. (ACJ)- Not likely
  5. Posterior impingement (internal) –> has posterior pain but not lateral
  6. Not OA
  7. Possible instability (less likely)

When is it restricted?

  • Cocking
  • Deceleration
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13
Q

Patient 3

  • 20 yo. A grade cricket player – outfield
  • Dominant arm
  • Progressive restriction with throwing with discomfort- Pain in EOR
  • AROM pain EOR elevation
  • Increased with o/p- Overpressure (PROM)
  • Fit
  • Perhaps inferior angle of scapula winging

What are 7 types of tests for differential diagnosis?

A
  1. Cuff impingement tests
  2. Cuff integrity tests
  3. Scapula facilitation
    • Perhaps tightness restricted with anterior tilt
    • perhaps tight / overactive pec minor- Soft tissue
    • Tight posterior shoulder- Can’t get his scapula on the bed
  4. Labral tests
  5. Palpation of ACJ
  6. Imaging USS +/- xray
  7. Unresponsive
  • AP glide in IR to stretch the posterior structures of the shoulder
  • IR exercises in abduction –> so not impinging
  • Overactive
  • Forward HOH
  • Scapular position
  • Motor control or flexibility
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14
Q

Patient 3

  • 20 yo. A grade cricket player – outfield
  • Dominant arm
  • Progressive restriction with throwing with discomfort- Pain in EOR
  • AROM pain EOR elevation
  • Increased with o/p- Overpressure (PROM)
  • Fit
  • Perhaps inferior angle of scapula winging

What are 14 treatments?

A
  1. Scapula facilitation
  2. Scapula soft tissue
  3. HOH posture
  4. Other structures
    • Tx spine other soft tissue
  5. Load management
  6. Motor
  7. Have they got PROM
  8. Pec Minor / post shoulder / other
  9. Soft tissue +/- cuff function
  10. Manual therapy / soft tissue / motor
  11. Advice / sport specific
    • Does he need to stop/continue sport
  12. Scapula control and strength
  13. Rotator cuff (control) and strength
  14. Kinetic chain
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15
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What are 6 differential diagnosis?

A
  1. Adhesive capsulitis- Possible
  2. GH arthritis- 3 weeks ago –> nothing
  3. Major cuff tear
    • Less likely due to trauma?
  4. Cuff arthropathy
    • Less likely due to trauma?
  5. Acute bursitis
    • Painful restrictive shoulder –> possible
  6. Cuff tendinopathy
    • Not likely
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16
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What are 6 types of tests for differential diagnosis?

A
  1. No injury
  2. No previous shoulder problems
  3. PROM = AROM pain limited (not stiff)
  4. No crepitus
  5. Cuff impingement tests unable
  6. Isometric strength appears intact but generally pain limited
17
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What are 2 symptoms of adhesive capsulitis?

A
  1. Specific pattern of ER > Abd > IR (HBB)
  2. Behaviour of symptoms with further questioning – pain initially and now increasingly restricted ROM
  • Adhesive capsulitis symptom
  • ER is okay for lower ranges of flexion
  • IR is less but not as bad
18
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What is a symptom of acute bursitis (=/- tendon etc)?

A

Next couple of weeks are the proof

19
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What are 2 symptoms of cuff injury?

A

Muscle testing was not

directionally specific (other

features stronger signs)

• But these tend to have a more

diffuse restriction of mvt

20
Q

Patient 4

  • 55 yo female
  • No injury
  • Worsening shoulder pain in the last 3/52
  • Guarded mvt / Diff undressing
  • 1100 of flexion, 1000 abd, 600 ER,
  • HBB to PSIS
  • Pain limited and PROM ISQ
  • Scapula dyskinesia – no change with facilitation

What are 3 treatments staged to pathology and progressively impairment based?

  • Pain
  • ROM
  • Scapula dyskinesia
A
  1. Gentle and non-provocative manual therapy
    • Increase or de-load subacromial space (longitudinal caudad glides)
  2. Self maintenance
    • PROM not exacerbate pain
    • Strength even if isometric
  3. (Inflammatory treatment) ice
  4. Analgesia / NSAIDs / early c/s?
  5. (Hydrodilatation?)
  6. Progressive increase of manual therapy and stretching and overall exercise – test to the stage
  7. If any role in addressing scapula dyskinesia till late stage
21
Q

Patient 5

  • 55 yo female triathlete
  • Pain for 6/12 but now affecting swim and home duties (reaching)
  • Perhaps some increased training in last 3/12 only
  • Mid range pain with elevation
  • Restricted ROM HBB and describes as tight
  • Scapula dyskinesia
  • Fwd HOH

What are 4 differential diagnosis?

A
  1. Rotator cuff (SAI)
  2. Instability
  3. Labral injury
  4. ACJ unlikely
22
Q

Patient 5

  • 55 yo female triathlete
  • Pain for 6/12 but now affecting swim and home duties (reaching)
  • Perhaps some increased training in last 3/12 only
  • Mid range pain with elevation
  • Restricted ROM HBB and describes as tight
  • Scapula dyskinesia
  • Fwd HOH

What are 5 types of test for differential diagnosis?

A
  1. Impingement test painful ie positive
  2. Apprehension test painful but not describing apprehension
  3. Describes a little easier with relocation
  4. Isometric Abd and ER shoulder pain
  5. Sleeper test restricted (200)
  6. ACJ not tender
23
Q

Patient 5

  • 55 yo female triathlete
  • Pain for 6/12 but now affecting swim and home duties (reaching)
  • Perhaps some increased training in last 3/12 only
  • Mid range pain with elevation
  • Restricted ROM HBB and describes as tight
  • Scapula dyskinesia
  • Fwd HOH

What are 6 treatments for differential diagnosis?

  • Scapula pattern
    • Identify if scapula muscle weakness
  • Load effect
  • Rotator cuff
A
  1. Scapula - demonstrated significant improvement – early aspect to address
    • Progressively addressing functional point in range
  2. Articular and soft tissue impairments
    • Manual therapy and stretching
  3. Load management relative to symptom provocation
  4. Rotator cuff rehab
    • Progressively addressing functional point in range
  5. Overall shoulder strength
    • And at specific point in range
  6. Swimming assessment at appropriate time point
    • Poor rotation in the pool

Significant improvement 6- 8 weeks and 3 months –> better

PHTY3120 (29 decks)

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