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PHTY3120 > L3: Clinical reasoning in examination of the shoulder- Overview > Flashcards

L3: Clinical reasoning in examination of the shoulder- Overview Flashcards

1
Q

What are the 5 components of the shoulder examination?

A
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2
Q

What are the 3 purposes of the patient history and interview?

A
  1. Direct and prioritise your physical examination
  2. Develop your primary hypothesis and differential diagnoses
  3. Determine the inter-relationship of the biopsychosocial factors/context for the patient
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3
Q

What are the 3 primary compliants that can be identified?

A
  1. Pain… primary problem, or restricting function
  2. Functional impairment…
  3. Physical impairment… stiffness, instability, weakness (altered movement)
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4
Q

What are the 2 questions to ask at first in the subjective assessment?

A
  1. What brought you here today?
  2. What can I do for you today?
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5
Q

What are 7 things to ask in the patient history and interview?

A
  1. Body chart
  2. Adjacent structures
  3. Behaviour of symptoms
  4. History
  5. Other questions
  6. Special questions
  7. Patient’s goals and expectations of treatment
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6
Q

What are 5 features of the body chart in the patient history and interview?

A
  1. Area or region of pain – local, focal/diffuse, travel above/below shoulder
  2. Nature & quality of symptoms – e.g. sharp, ache, burn, throb, stiff
    • Acute injury? Inflammatory? Neural?
  3. Severity of symptoms - e.g. pain numerical rating scale (0-10)
  4. Adjacent joints
    • Cervical spine or elbow
  5. Other symptoms – pins & needles, numbness, weakness
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7
Q

What are 5 characteristics of the axillary nerve (C5,6) for the patient history and interview?

A
  1. Passes inferiorly & laterally along the posterior wall to exit
  2. the axilla through the quadrangular space, then passes posteriorly around the surgical neck of the humerus
  3. Innervates deltoid and teres minor
  4. Branches into superior lateral cutaneous nerve (loops around posterior margin of deltoid to innervate skin in that region)
  5. Accompanied by posterior circumflex humeral artery
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8
Q

What are 3 components of the “adjacent structures” in the patient history and interview?

A
  1. Somatic referred pain
  2. Neural
  3. Visceral
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9
Q

What are the 2 characteristics of the “adjacent structures- somatic referred pain” in the patient history and interview?

A
  1. Cervical structures
  2. Thoracic structures – 1st rib, 2nd rib (Boyle 1999); tends to be more posterior shoulder
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10
Q

What are the 2 characteristics of the “adjacent structures- neural” in the patient history and interview?

A
  1. C5 supplies shoulder
  2. Number of dermatomes pass over the shoulder
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11
Q

What are the 2 characteristics of the “adjacent structures- visceral” in the patient history and interview?

A
  1. Post-surgical – diaphragmatic irritation due to air in abdominal cavity (C3,4,5)
  2. Cardiac referral
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12
Q

What are 7 components of the “behaviour of symptoms” in the patient history and interview?

A
  1. 24 hrour picture
  2. Severity
  3. Irritability
  4. Pain, disability, physical restriction
  5. Aggravating and easing factors
  6. Somatic vs neurogenic
  7. Sleep disturbance
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13
Q

What are the 2 characteristics of the “24 hour picture” in “behaviour of symptoms” in the patient history and interview?

A
  1. Behaviour through the day
  2. Relationship to rest and activity
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14
Q

What is a characteristic of the “severity” in “behaviour of symptoms” in the patient history and interview?

A

Intensity of pain

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15
Q

What are 3 characteristics of the “irritability” in “behaviour of symptoms” in the patient history and interview?

A
  1. Are symptoms exacerbated easily?
  2. How long does it take to settle, and what can be done to settle?
  3. Determines how hard you go with physical examination and treatment
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16
Q

What are 4 characteristics of the “aggravating and easing factors” in “behaviour of symptoms” in the patient history and interview?

A
  1. Need to ensure that you are focused on their main presenting features – pain vs. weakness vs. instability vs. stiffness – don’t just ask about pain!
  2. Activity
  3. Ergonomics / sports analysis
  4. Consider symptoms with different static, dynamic, sustained, momentary positions
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17
Q

What are 4 characteristics of the “aggravating and easing factors- Activity” in “behaviour of symptoms” in the patient history and interview?

A
  1. sport, work tasks, ADL
  2. dynamic or static postures
  3. Are symptoms aggravated with arm by side or carrying, through range (rotator cuff), at end of range (ACJ, instability)?
  4. What activities have they changed or avoided due to shoulder problem?
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18
Q

What are 3 characteristics of the “aggravating and easing factors- Ergonomics / sports analysis” in “behaviour of symptoms” in the patient history and interview?

A
  1. throwers in cocking phase – possible internal impingement
  2. feeling of weakness or giving way (e.g. in abduction/ER)
  3. computer set up – e.g. mouse position
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19
Q

What are 4 features of the “aggravating and easing factors- Consider symptoms with different static, dynamic, sustained, momentary positions” in “behaviour of symptoms” in the patient history and interview?

A
  1. Pain when arm by side:
    1. Inferior instability
    2. Scapular downward rotation – alters GHJ position; tractions neural tissues
    3. Acute bursitis – tend to hurt all the time
  2. Pain through range:
    1. Rotator cuff tendinopathy or tear; bursa
    2. Biceps loading superior labrum (SLAP lesion)
    3. Impingement of the internal/external rotators
  3. End of range:
    1. ACJ
    2. stiff shoulders (adhesive capsulitis, OA)
    3. instability
  4. Load on shoulder:
    1. Carrying load on shoulder - loads ACJ
    2. Altered scapular stability – increased shoulder load e.g. during overhead activity; is it due to
    3. problem with long thoracic or accessory nerve?
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20
Q

What are 3 problems in “pain when arm by side” of the “aggravating and easing factors- Consider symptoms with different static, dynamic, sustained, momentary positions” in “behaviour of symptoms” in the patient history and interview?

A
  1. Inferior instability
  2. Scapular downward rotation – alters GHJ position; tractions neural tissues
  3. Acute bursitis – tend to hurt all the time
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21
Q

What are 3 in “pain through range” of the “aggravating and easing factors- Consider symptoms with different static, dynamic, sustained, momentary positions” in “behaviour of symptoms” in the patient history and interview?

A
  1. Rotator cuff tendinopathy or tear; bursa
  2. Biceps loading superior labrum (SLAP lesion)
  3. Impingement of the internal/external rotators
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22
Q

What are 3 problems in “end of range” of the “aggravating and easing factors- Consider symptoms with different static, dynamic, sustained, momentary positions” in “behaviour of symptoms” in the patient history and interview?

A
  1. ACJ
  2. stiff shoulders (adhesive capsulitis, OA)
  3. instability
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23
Q

What are 2 problems in “load on shoulder” of the “aggravating and easing factors- Consider symptoms with different static, dynamic, sustained, momentary positions” in “behaviour of symptoms” in the patient history and interview?

A
  1. Carrying load on shoulder - loads ACJ
  2. Altered scapular stability – increased shoulder load e.g. during overhead activity; is it due to problem with long thoracic or accessory nerve?
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24
Q

What are 2 characteristics of the “Somatic vs. neurogenic (nerve root, brachial plexus, peripheral nerve) referral” in “behaviour of symptoms” in the patient history and interview?

A
  1. Are symptoms exacerbated by shoulder vs. neck movement
  2. Consider positions that sensitise neural tissues (e.g. ULTTs)
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25
Q

What are 6 characteristics of the “Sleep disturbances” in “behaviour of symptoms” in the patient history and interview?

A
  1. Common symptom
  2. Systemic inflammatory conditions – often report night pain, not relieved with mvt
  3. Ipsilateral side lying: direct compression of ACJ, tendons, ribs
  4. Contralateral side lying: positioned in horizontal adduction, traction of posterior structures
  5. Supine: mild extension (may stress anterior structures)
  6. Typical position of comfort is loose packed position – 30o flex, 30o abd, 0o rotation
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26
Q

What are 2 components of the “History” in the patient history and interview?

A
  1. Current history
  2. Past history
27
Q

What are 4 characteristics of the “Current history” in “History” in the patient history and interview?

A
  1. Was there an event or incident that started this – ‘moment in time’
    • Acute traumatic event; chronic, recurrent events (how often?)
    • Specific details e.g. tackle onto shoulder – ACJ
    • What happened next? Dislocation with spontaneous relocation, or medical relocation
  2. Relationship to other features / structures e.g. neck symptoms; how do they affect each other
  3. Management – physio, medications, surgery
  4. Current status
28
Q

What are 4 characteristics of the “Past history” in “History” in the patient history and interview?

A
  1. Is this episode similar or different to previous episodes?
  2. Past trauma e.g. fractures, dislocations, previous surgeries
  3. Recurrent injuries e.g. giving way, subluxation, dislocation
  4. Past management:
    • Corticosteroid injection
      • Frequent injections = decrease quality of tissues (only temporary beneficial effect)
    • Surgery
    • Relocations
    • Nothing…?
29
Q

What are 4 components of the “Other questions” in the patient history and interview?

A
  1. Social situation
    • Home situation
    • Social support
  2. Occupation – current, previous
  3. Physical activity
  4. Recreational activities
30
Q

What are 7 components of the “Special questions” in the patient history and interview?

A
  1. Shoulder
  2. General health and relevant medical history
  3. Medications
  4. Weight loss
  5. Family Hx – inflammatory or connective tissue conditions, hypermobility
  6. Investigations and results (and relevance)
  7. Treatment – injections, medication, self Mx, other health practitioners
31
Q

What are 8 characteristics of the “Shoulder” in “Special questions” in the patient history and interview?

A
  1. Slipping – instability; particular direction?
  2. Popping
  3. Jamming inside
  4. Catching and giving – impingement, labrum, LHB
  5. Clicking, locking – intra-articular, impingement
  6. Crepitus
    • Which joint?
    • Intra- or extra-articular?
    • Is it associated with pain?
    • May indicate OA
  7. Pins & needles, numbness, weakness
    • Indicates neural irritation or compromise
    • Possible neural traction due to depressed scapula
  8. ‘Dead arm’ feeling
    • Could indicate thrower’s shoulder or thoracic outlet
    • Lose control and/or feeling of arm
32
Q

What are 6 characteristics of the “General health and relevant medical history” in “Special questions” in the patient history and interview?

A
  1. Diabetes (adhesive capsulitis)
  2. Thyroid (adhesive capsulitis)
  3. Surgery – cervical spine, shoulder
  4. Systemic steroid medication
  5. Medical history
    • relevance to shoulder and sinister pathology (e.g. cardiac history, lung cancer, recent abdominal surgery)
  6. Mental health
33
Q

What are 10 sinister pathology (red flags) in patient history and interview?

A
  1. History of cancer; symptoms and signs of cancer (night pain/sweats); unexplained deformity, mass, or swelling – tumour?
  2. Red skin, fever, systemically unwell – infection?
  3. Trauma:
    • Did they have an epileptic fit, electric shock; is there a loss of rotation and normal shape – unreduced posterior GHJ dislocation
    • Acute disabling pain, significant weakness, positive drop arm test – acute RC tear
  4. Unexplained significant sensory or motor deficit – neurological lesion?
  5. Metastatic disease – primary / secondary tumour – referred symptoms
  6. Infections in shoulder, other infections e.g. lung TB
  7. Posterior dislocations at SCJ
  8. Fractures (HOH, GT, clavicle), dislocations, avascular necrosis
  9. Neurovascular compromise
  10. Weakness that is not pain inhibited – e.g. C5 radiculopathy
34
Q

What are 4 red flags from referred pain to the shoulder in patient history and interview?

A
  1. Visceral:
    • Heart – infarct, angina
    • Diaphragm
    • Lung
    • Liver
  2. Tumours:
    • Local shoulder tumours (e.g. bone tumour in proximal humerus)
    • Pancoast tumours (lung apex): 90% have shoulder symptoms (PHx of cancer e.g. lung, breast, melanoma). Will present with other symptoms (e.g. Horner’s syndrome)
  3. Cervical myelopathy (damage to spinal cord) e.g. degenerative
    • Typically older
    • Shoulder and neck pain; weakness; may have arm and hand symptoms, or leg symptoms
    • Other neurological signs e.g. hyper-reflexia
  4. Polymyalgia rheumatic
    • Inflammatory; acute onset bilateral shoulder girdle and hip girdle pain
    • Needs medical management (steroids)
35
Q

What are 8 yellow flags for rotator cuff problems in patient history and interview?

A
  1. Older age (50 + years for RTW)
  2. Higher perceived pain intensity
  3. Longer duration of symptoms
  4. Previous injury
  5. Extensive sick leave taken over the previous 3 years prior to injury, unemployment
  6. Co-morbidities
  7. Previous shoulder pain or poor perceived general health
  8. Avoidance of activity for fear of pain and harm
  9. Perceived high job demands and low control at work (job satisfaction)
  10. Higher body mass index
  11. Poor social support

Inconsistent evidence on the influence of:

  • Being female with more than 28 days of sick leave due to pain
  • Having a workers compensation claim
36
Q

What are the 4 purposes of the physical examination?

A
  1. Confirm primary diagnosis and exclude alternatives
  2. Assess functional restrictions
  3. Identify impairments
  4. Prioritise treatment/management approach

Must get consent

  • Patient should be suitably undressed so you can view their shoulder, neck and thorax
37
Q

What are 6 components of the physical exmination?

A
  1. Observation
  2. Movement examination
  3. Palpation
  4. Special tests
  5. Assessment of the muscle system
  6. Assessment of the sensorimotor system
    7.
38
Q

What are 3 characteristics of “Observation in the physical examination?

A
  1. Normal resting position of scapula
  2. Humeral head should sit ~1/3 anterior to acromion
  3. Look for unilateral signs of muscle wasting – may indicate neuropathy
    • Supraspinatus & infraspinatus – suprascapular nerve
    • Deltoid & teres minor – axillary nerve
    • Trapezius & sternocleidomastoid – accessory nerve
    • Serratus anterior – long thoracic nerve
    • Rhomboids & levator scapula – dorsal scapular nerve
39
Q

What are 4 characteristics of “Movement examination” in the physical examination?

A
  1. Symptom modification tests (treatment direction test)
  2. PROM
  3. Accessory glides
  4. Clear adjacent joints (Cx spine, Tx spine, neural structures, elbow)
40
Q

What are 3 characteristics of “Movement examination- symptom modification tests (TDT)” in the physical examination?

A
  1. What happens to the patient’s symptoms when you correct an abnormal position/movement of the shoulder girdle?
    • Static posture or during dynamic movement
    • e.g. facilitate ideal sitting posture (cervical, thoracic and lumbar spines)
    • e.g. manually facilitate upward rotation of the scapula during arm elevation
    • e.g. manually/actively glide humeral head posteriorly during movement
  2. If symptoms are relieved with correction, indicates where to start treatment
  3. Shoulder Symptom Modification Procedure
41
Q

What are 3 characteristics of “Movement examination- Accessory glides” in the physical examination?

A
  1. GHJ: AP, PA, inferior, lateral (in neutral, 90o abduction with ER)
  2. ACJ: AP, PA, inferior
  3. SCJ: AP, superior, inferior
42
Q

What are 4 characteristics of “Movement examination- Clear adjacent hoints (Cx spine, Tx spine, neural structure, elbow)” in the physical examination?

A
  1. Full AROM; passive examination if relevant
  2. Axillary nerve (sensory & motor): sensation over deltoid insertion; motor =deltoid, teres minor
  3. Long thoracic nerve (motor): serratus anterior
  4. Accessory nerve (motor): trapezius
43
Q

What are 8 things to feel for in palpation in the physical examination?

A
  1. Pain/tenderness
  2. Temperature
  3. Swelling
  4. Deformity/alignment
  5. Crepitus
  6. Thickening, scarring
  7. Muscle spasm, wasting
  8. Lumps, bumps, unusual things
44
Q

Where are 4 places you palpation in the physical examination?

A
  1. Location of symptoms
  2. Other relevant areas
  3. Soft tissue and bony structures
  4. Thoracic spine
  • Over GT, LT, LHB Coracoid process
  • Acromiohumeral interval
  • Lateral upper arm
  • RC muscles & tendons
45
Q

What are 3 special tests for the GHK- articular bias for instability in the physical examination?

A

Instability

  1. Sulcus sign
  2. Load-shift
  3. Apprehension
46
Q

What are 3 special tests for the GHJ- articular bias for labral injury in the physical examination?

A

Labral tear

  1. O’Brien’s
  2. Bicep load
  3. Crank
47
Q

What are 2 special tests for the GHJ- articular bias for stiffness/loss of ROM in the physical examination?

A
  1. Anterior capsule length test
  2. Posterior capsule length test
48
Q

What are 2 special tests for the GHJ- articular bias for impingement in the physical examination?

A
  1. Neer’s
  2. Hawkins Kennedy
49
Q

What are 2 special tests for the GHJ- muscular bias for rotator cuff in the physical examination?

A
  1. Empty can
  2. ER muscle test
  3. Gerber’s
50
Q

What are 2 special tests for the GHJ- muscular bias for LHB in the physical examination?

A
  1. Speed’s
  2. Yergason’s
51
Q

What are 2 special tests for the ACJ in the physical examination?

A
  1. Horizontal adduction
  2. Shrug
52
Q

What is the special test for hypermobility?

A

Beighton’s score

53
Q

What are the 5 components of the Beighton’s score?

A
  1. Passive DF of 5th MCPJ >=90o
  2. Passive elbow hyperextension >=10o
  3. Passive knee hyperextension >=10o
  4. Passive opposition of thumb to flexor side of forearm
  5. Forward trunk flexion, knees straight, palms flat on floor

Total score /9 (higher score indicates greater laxity)

54
Q

What are 8 components of the “Assessment of the muscle system” in the physical examination?

A
  1. Isometric muscle tests
  2. Muscle strength tests
  3. Muscle endurance tests
  4. Muscle power tests
  5. Muscle length tests
  6. Motor control – e.g. HH positioning
  7. Inner range holds
  8. Eccentric control
55
Q

What is the component in the “Assessment of the sensorimotor system” in the physical examination?

A

Joint position sense

  • Passively place in position (eyes closed)–> replicate position
56
Q

What are 3 characteristics of the patient-reported outcome measures (outcome measures for the shoulder)?

A
  1. Measures in which the patient provides their own perspective of a health condition or treatment
  2. Can be specific to a region (e.g. shoulder), or to a treatment (e.g. exercise)
  3. Select based on:
    • Specific clinical outcome to be measured e.g. pain, function, activity
    • Specific pathology e.g. instability, rotator cuff pathology
    • Whether require disease-specific, region-specific, or generic outcome is required
57
Q

What are the 5 types of imaging on the shoulder?

A
  1. Xray
  2. Ultrasound
  3. CT
  4. MRI
  5. Arthrography
58
Q

What are the 3 characteristics of X-rays for imaging of the shoulder?

A
  1. Only visualise bone and other calcified tissue
  2. Views: AP, AP with IR/IR, axillary lateral,
  3. Useful for: excluding unusual pathology (e.g. AVN, dislocations, fractures, anatomical deficits); calcific tendinopathy; GHJ OA; impingement (sclerosis of anterior and/or lateral acromion or greater tuberosity); proximal humeral head migration (e.g. rotator cuff arthropathy)
59
Q

What are the 3 characteristics of Ultrasound for imaging of the shoulder?

A
  1. Only visualise soft tissues (US waves do not travel through bone)
  2. Cross-section through tissues; can be static or dynamic
  3. No radiation
  4. Useful for: rotator cuff tendons (tears) and muscles; long head of biceps; bursa (e.g. thickening); calcific tendonitis; abnormal fluid collection
60
Q

What are the 3 characteristics of CT for imaging of the shoulder?

A
  1. Higher resolution imaging of bone; no soft tissue
  2. High dose of radiation
  3. Useful for: bony detail; 3D reconstruction
61
Q

What are the 4 characteristics of MRI for imaging of the shoulder?

A
  1. Can visualise all tissues, although bone detail not as clear as with CT (depending on strength of MRI e.g. 1.5T, 3T)
  2. Multiplanar images
  3. No radiation
  4. Useful for: soft tissues (e.g. rotator cuff tear)
62
Q

What are the 2 characteristics of Athrography for imaging of the shoulder?

A
  1. Joint injected with dye before imaging with CT or MRI – better visualisation of structures
  2. Useful for: capsular attachments, labrum, bony Bankart lesions, Hill- Sachs’ lesions
63
Q

____ are important to understand the patient’s perspective on their shoulder condition, and how it is changing over time

A

PROMs

64
Q

Imaging is often used for shoulder pain, injury and pathology

… select ____appropriate to the tissue of interest

… imaging findings not always correlated with symptoms

A

modality

PHTY3120 (29 decks)

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