L5-6: Clinical reasoning shoulder examination Flashcards
1
Q
What are 6 common causes of shoulder pain?
A
- Glenohumeral instability (traumatic, atraumatic, congenital)
- Rotator cuff pathology (strain, tear, tendinopathy)
- Biceps-related pathology (SLAP lesions, biceps tendinopathy, tenosynovitis)
- Glenohumeral IR deficit (GIRD)
- ACJ & SCJ pathology: sprain, fracture (e.g. clavicle, dislocation
- Scapular dyskinesis
2
Q
What is the most common reason for shoulder pain with no mechanical reason –> insidious?
A
Scapular dyskinesis
3
Q
What are 5 less common causes of shoulder pain?
A
- Other muscle tears (pectoralis major, long head of biceps)
- Adhesive capsulitis
- Neurovascular entrapment or traction injury
- Close to HOH and clavicle
- Fractures (scapula, humerus, coracoid process stress fracture)
- Snapping scapula
- Glides over structures and causes a noise
4
Q
What are 3 causes of shoulder pain that should not be missed (red flags)?
A
- Somatic referred pain (cervical spine, thoracic spine, myofascial structures)
- Tumour (bone tumours in proximal humerus)
- Visceral referred pain (e.g. diaphragm, gall bladder, heart (left shoulder pain), spleen, apex of lungs)
5
Q
How does diaphragm act as visceral referred pain for the shoulder?
A
Surgery where procedure has resulted in irritation of diaphragm –> causes shoulder painSurgery where procedure has resulted in irritation of diaphragm –> causes shoulder pain
6
Q
What are 5 possible causes of traumatic onset shoulder pain?
A
- instability
- rotator cuff strain/tear
- SLAP lesion
- ACJ injury
- SCJ injury
7
Q
What are the 3 categories of instability?
A
- Traumatic unidirectional instability
- Acquired instability due to overstress (sports-specific- Eg. Throwing athlete)
- Multidirectional instability
Can occur in combination:
- e.g. athlete with multidirectional instability may sustain a traumatic dislocation
8
Q
What is the stanmore classification?
A
For symptoms to occur, there needs to be a disturbance of one or more of the following factors, in isolation or together:
- Capsulolabral complex and its proprioceptive mechanism
- Rotator cuff
- Surface arc or area of contact between glenoid and humeral head
- Central/peripheral nervous system
9
Q
For symptoms to occur, there needs to be a disturbance of one or more of the following factors, in isolation or together. What are the 4 factors?
A
- Capsulolabral complex and its proprioceptive mechanism
- Rotator cuff
- Surface arc or area of contact between glenoid and humeral head
- Central/peripheral nervous system
10
Q
What is the difference between hypermobility and instability?
A
Important to recognise that hypermobility is not instability
- hypermobility: normal variant; related to passive stabilisation & ROM e.g. adolescents with generalised ligamentous laxity (Beighton score)
- instability: pathological (e.g. tissue injury)
- Associated with symptoms (eg. patient reports pain, apprehension, weakness or instability)
11
Q
What is hypermobility?
A
normal variant; related to passive stabilisation & ROM
- e.g. adolescents with generalised ligamentous laxity (Beighton score)
12
Q
What is instability?
A
pathological (e.g. tissue injury)
- Associated with symptoms (eg. patient reports pain, apprehension, weakness or instability)
13
Q
What is a TUBS?
A
traumatic unidirectional instability with Bankart lesion
14
Q
What is the most common type of traumatic instability?
A
~95% are anterior dislocation - arm forced into excessive abduction and ER
15
Q
What is the position of the arm in an anterior dislocation (traumatic instability)?
A
arm forced into excessive abduction and ER
16
Q
What is the main pathology of traumatic instability (dislocation)? What is the other 3 pathologies?
A
- Typically results in Bankart lesion – labral attachment at the anterior glenoid margin
- bony Bankart lesion - fracture of the anterior glenoid rim
- Hill-Sachs lesion – posterior compression fracture of the humeral head
- injury to posterior or superior labrum
17
Q
What is the clinical features of traumatic instability of the shoulder?
A
18
Q
What are 4 features of acute traumatic injury of shoulder instability in the subjective examination?
A
- Often clear description – specific history of dislocation/relocation – ‘moment in time’
- Sudden onset of acute shoulder pain
- May describe feeling of shoulder ‘popping out’
- Recurrent episodes
19
Q
What is a feature of reccurent instability of shoulder instability in the subjective examination?
A
Typically less trauma required for recurrent episodes
- High risk for re-dislocation –> surgery might be an option
20
Q
What are 3 features of chronic instability of shoulder instability in the subjective examination?
A
- Instability episode with minimal trauma
- May have sensation of popping out or shifting of the humeral head, without a frank dislocation
- May describe hundreds of episodes
21
Q
What are 4 impairments of shoulder instability in the subjective examination?
A
- Patient will describe specific aggravating positions or movements that match the direction of instability
- Anterior instability: abduction/ER
- Posterior instability: posterior directed force applied to the shoulder
- Multidirectional instability: wide range of movements; may also affect other shoulder or other joints
22
Q
What is the difference between instability and dislocation?
A
- Dislocation: arm will feel heavy, loss of strength; may or may not be obvious deformity (anterior vs. posterior dislocation)
- Instability: feeling of slipping, subluxation, dead arm; spontaneously relocate
23
Q
What is dislocation of the shoulder?
A
arm will feel heavy, loss of strength; may or may not be obvious deformity (anterior vs. posterior dislocation)
- Generally won’t pop back in (esp. first time dislocation)
24
Q
What is instability of the shoulder?
A
feeling of slipping, subluxation, dead arm; spontaneously relocate
- Generally won’t pop back in (esp. first time dislocation)
25
What is the sensitivity and specificity of the physical examination of shoulder instability?
26
What are 3 shoulder special tests for instability in the physical examination to confirm the type of instability?
1. Load and shift test – positive test (increased ROM) – anterior or posterior instability
2. Apprehension test (subluxation/relocation) – positive test (apprehension with ER; reduced symptoms with relocation) – anterior instability (traumatic or acquired)
* Most useful test to identify shoulder instability
3. Sulcus sign (Gap between acromion and HOH) – positive test (increased ROM) + positive test for AP instability (inferior)
* Patients may not experience pain during these tests
* Consider: if positive relocation test, can the patient replicate this by actively drawing their humeral head posteriorly? Indicates treatment direction
27
What are 3 shoulder special tests for the labrum to test of there is a structural lesion?
1. O’Brien’s active compression test
2. Crank test
3. Biceps load test – SLAP lesion
28
For shoulder instability, exclude _______ if patient has had an acute trauma
axillary nerve palsy
29
What is the neural irritation of shoulder instability?
Anteriorly subluxing humeral head
30
Where is palpation in shoulder instability?
May not be a specifically tender structure on palpation (intra-articular- might be too deep to palpate), but negative findings on palpation may be useful
31
What are 3 observations in the physical examamination for muscle function?
1. Look for any muscular impairment (timing, strength, endurance)
* If shoulder has a structural lesion (e.g. labrum), muscles become key stabilisers
2. Scapulothoracic control
* Position is important for stability of the GHJ
* How does ST control change with load (e.g. no load vs. low load vs. functional load vs. arm lever)
3. Glenohumeral control
* GH force couple – subscapularis and infraspinatus/teres minor
* Often have rotator cuff impairment, especially subscapularis facilitation
32
What is a characteristicof muscular impairment (timing, strength, endurance) for muscle function in the physical examination?
If shoulder has a structural lesion (e.g. labrum), muscles become key stabilisers
33
What are 2 characteristics of spaculothoracic control (timing, strength, endurance) for muscle function in the physical examination?
1. Position is important for stability of the GHJ
2. How does ST control change with load (e.g. no load vs. low load vs. functional load vs. arm lever)
34
What are 2 characteristics of glenohumeral control (timing, strength, endurance) for muscle function in the physical examination?
1. GH force couple – subscapularis and infraspinatus/teres minor
2. Often have rotator cuff impairment, especially subscapularis facilitation
35
Which GHJ dislocation is less common?
Posterior GHJ dislocation
* Not as obvious as anterior dislocation
36
What is the mechanism of injury for a posterior GHJ dislocation?
Direct trauma or fall on outstretched hand (FOOSH) with arm in adduction or IR
37
What are 5 clinical features of the posterior GHJ dislocation for shoulder instability?
1. History of acute trauma
2. Sudden onset of acute shoulder pain
3. May have had seizure (e.g. epilepsy, electrocution)
4. Limited external rotation
5. X-ray (AP view): humeral head does not appear displaced, but is in IR – rounded contour (light bulb)
38
What is a SLAP lesion?
Injuries to the labrum that extend from anterior to the biceps tendon to posterior to the tendon (labral injuries)
39
What are the 2 ways to describe the 4 ways of labral injuries (SLAP lesions)
* 4 types (based on severity & instability)
* Can be stable or unstable
40
What are 4 clinical features of labral injuries (SLAP lesions)?
1. Mechanism of injury: excessive traction on labrum through LHB (e.g. carrying, dropping or catching heavy object); fall onto hand when behind body; throwing
2. Pain localised to the posterior or posterosuperior joint line, esp. in abduction
3. Aggs: overhead movement, hand behind back
4. May have popping, catching, grinding (Special symptoms)
41
What are 6 mechanism of injuries for a traumatic SLAP lesion (labral injuries)?
1. Overhead activities (abduction & ER) – torsional force at base of biceps, stress on IGHL
2. Fall on outstretched hand (especially when behind body)
3. Sudden pull on LHB attachment to labrum (e.g. carrying, dropping or catching heavy object, violent biceps contraction)
4. Eccentric biceps contraction with deceleration of arm (e.g. during throwing)
5. Compression injury (direct blow)
6. Can occur in throwing athletes or weightlifters due to repetitive shoulder motion
42
What are 2 mechanism of injuries for a Bankart lesion (labral injuries)?
1. Associated with anterior dislocations
2. May also have a bony Bankart lesion
43
What are 2 mechanism of injuries for a Traumatic or degenerative tears (labral injuries)?
1. Repetitive overuse with anterior translation – fraying/traction LHB
2. Repeated microtrauma (similar to meniscus in knee)
44
What are 3 main features of labral injuries in the subjective examination?
1. Vague deep joint pain (Intra-articular (in the joint))
2. Issues with instability
* May have apprehension signs
* Clicking, locking, slipping – especially associated with overhead activity
* Increased humeral head translation
3. Pain with throwing and loss of power (Due to loss of stability)
45
What are 3 shoulder special tests for labrum?
1. O’Brien’s active compression test – positive test (pain) – labral injury (SLAP)
2. Crank test – positive test (pain) – labral injury
3. Biceps load test – positive test (pain, apprehension, weakness) – SLAP lesion
4. May also have positive instability tests e.g. anterior apprehension if Bankart lesion
46
What are 3 tests for biceps tendon lesions?
1. Speeds test
2. Yergason’s test
3. Palpation
Local tendinopathy, acute tendinitis, tendon tear
47
What are 2 characteristics of imaging for instability and labral injuries?
1. If you suspect there is a specific anatomical deficit, could consider imaging to confirm (referral to GP)
2. Labral injuries can be difficult to diagnose clinically
* MRI +/- contrast injections (arthrogram) (Can be quite invasive)
* BUT consider if imaging is necessary…will the outcome influence your management?
* Trial conservative management first?
48
What are 5 clinical features of rotator cuff tears?
1. Pain with overhead activity (e.g. throwing, putting shirt on/off
2. Painful arc ~70-120˚ abduction
* Due to the rotation component (tendon gets impinged during this range and then gets clear again)
3. Pain when sleeping on affected shoulder
4. Tender over tendon or insertion (supraspinatus, infraspinatus)
5. Pain +/- weakness with static muscle testing
49
What are 3 characteristics in the subjective exam for rotator cuff tear?
1. History of possible acute tear - specific incident / trauma / FOOSH
2. Acute extension of chronic tear / tendinopathy (even in previously pain-free shoulder)
3. Trauma:
* Need to consider fracture
* Female, elderly, osteoporosis history of steroid use – high probability of fracture
50
What are 3 characteristics in the physical exam and imaging for rotator cuff tear?
1. Acute or chronic loss of AROM – may be limited by weakness or pain
2. PROM is maintained
3. Size and site:
* Investigate with imaging (US, MRI)
* Capsular integrity tests (blending of RC tendons with capsule)
51
What does the ACJ look like?
52
What is the mechanism of injurt for an acute ACJ injury?
Fall onto point of shoulder
53
What are the types/grades of acute ACJ injuries?
* High-grade injuries (III-IV) – loss of strut function to stabilise the scapula, GHJ and arm
* Altered scapular mechanics in type III ACJ separations
54
What are 3 characteristics of an acute ACJ injury?
1. Specific site of pain – 1 finger
2. Dislocation:
* History of specific trauma
* Acute injury; pain and deformity (depending on grade of injury)
3. ACJ injury vs. arthritis:
* Age - \<30-40 years instability; \>30-40 years arthritis
* End of range pain
* Pain under compression (e.g. sleeping on affected side)
* Pain vs. end of range stiffness
55
What are 7 clinical features for an acute ACJ dislocation in the physical examination?
1. Grade 2 or 3 with step deformity
2. Pain
3. Thickened, swollen (depending on how much of capsule remains)
4. Bony thickening (arthritis)
5. Elevation is restricted by pain; may not be 90˚ elevation
6. Tender on palpation of AC joint line
7. Accessory glides hypermobile / unstable (may be pain restricted)
56
What are 8 clinical features for an acute ACJ injury in the physical examination?
1. Pain with horizontal adduction
2. Pain at end of range abduction
3. Pain with horizontal abduction
4. Pain when sleeping on painful side
5. ACJ tender on palpation
6. See/feel subluxation / instability
7. Scapular impairments:
* Is it a primary scapular impairment causing ACJ problem?
* Altered scapular postures – increased load / altered kinematics at ACJ
* Symptoms may be relieved by improving scapular position
* Is scapula position / impairment secondary to ACJ problem?
* Scapula thought to downward rotate with ACJ dislocation
* Altered biomechanics to rest of upper quadrant (Loss of scapulothoracic movement)
8. Broadly consider muscle strength and control (no muscles acting directly on the ACJ)
57
What are 8 possible causes for non-traumatic shoulder pain?
1. impingement
2. rotator cuff tendinopathy, tear
3. GIRD
4. multidirectional instability
5. scapular dyskinesis
6. LHB tendinopathy
7. adhesive capsulitis
8. GHJ/ACJ OA
9. rotator cuff arthropathy
10. acquired instability
58
What are 4 characteristics of acquired instability (overstress)?
1. Acquired sports-specific instability; acquired instability due to overstress syndrome (AIOS); Thrower’s shoulder
2. Anterior capsular laxity with acquired GHJ instability
3. Due to repetitive overhead motion (e.g. throwing)
4. May result in posterosuperior impingement (anterior translation of HH)
59
What are 4 clinical features of acquired instability (overstress) of the shoulder?
1. Recurrent shoulder pain during throwing (Related to specific activity)
2. May have recurrent subluxations or feeling of slipping (in certain positions)
3. ‘Dead arm’ – sudden inability to throw or smash + feeling of dead arm (During overhead, cocking position)
4. Can get chronic pain from impingement of rotator cuff tendons; may develop rotator cuff tendinopathy from recurrent impingementa
60
What is acquired instability (overstress) of the shoulder?
Acquired sports-specific instability; acquired instability due to overstress syndrome (AIOS); Thrower’s shoulder
61
What is the mechanism of injury for acquired instability (overstress) of the shoulder?
Due to repetitive overhead motion (e.g. throwing)
62
What does acquired instability of the shoulder (overstress) usually cause?
* Anterior capsular laxity with acquired GHJ instability
* May result in posterosuperior impingement (anterior translation of HH)
63
What are 4 characteristics of multi-directional instability of the shoulder?
1. Combination of 2-3 instabilities – anterior, posterior, inferior
2. Typically atraumatic
3. Often associated with generalised ligament laxity
4. May result from repetitive trauma (esp. at extremes of ROM) or direct blow
64
What is multi-directional instability of the shoulder?
Combination of 2-3 instabilities – anterior, posterior, inferior
65
Multiple-directional instability of the shoulder is usually _______ (traumatic/atraumatic)?
atraumatic
66
What is the mechanism of injury for multi-directional instability of the shoulder?
* Atraumatic
* May result from repetitive trauma (esp. at extremes of ROM) or direct blow
67
What does multi-directional instability of the shoulder cause?
Often associated with generalised ligament laxity
* Reliant on dynamic control through range (muscles)
68
What are 4 clinical features of multiple-directional instability of the shoulder?
1. Pain occurs in mid ranges of motion
2. indicates key role of altered muscle activation
3. decreased activity of lower trap & serratus ant
4. increased activity of pec
5. major/minor & lat dorsi
6. creates position of scapular protraction & glenoid tilting
69
What are 4 features of the acquired instability of the shoulder in the subjective examination?
1. Recurrent shoulder pain during throwing
2. May have recurrent subluxations or feeling of slipping (in certain positions)
3. ‘Dead arm’ – sudden inability to throw or smash + feeling of dead arm
4. May describe impingement type pain (posterior)
70
What are 3 features of the MDI of the shoulder in the subjective examination?
1. Describe instability in more than one direction (anterior, posterior, inferior)
2. Typically atraumatic, but may result from repetitive trauma or a direct blow
3. Pain typically in mid ranges of motion
71
What is the multifactorial aitiology of a roator cuff pathology (tendinopathy)?
72
Where does rotator cuff pathology (tendinopathy) typically begin?
On the inferior (articular) surface
* May be associated with partial tear
73
What are the 3 clinical features of a rotator cuff pathology (tendinopathy)?
1. Pain with overhead activity (e.g. throwing, putting shirt on/off
2. Painful arc ~70-120o abduction
3. Tender over tendon or insertion (supraspinatus, infraspinatus)
74
What is calcific tendinopathy as a rotator cuff pathology?
Deposition of calcium hydroxyapatite crystals within tendon over time; tends to spontaneously resorb (thought to be painful stage)
75
What tendon is most commonly affected by calcific tendinopathy (as a rotator cuff pathology)?
Most commonly supraspinatus tendon
76
What is the cause of calcific tendinopathy (rotator cuff pathology)?
Unknown cause – unlikely due to repeated impingement
77
What are 4 clincial features of calcific tendinopathy (rotator cuff pathology)?
1. Generally age \>40 years
2. Acute or chronic shoulder pain
3. Similar to impingement (primary)
4. Acute bursitis
78
\_\_\_\_\_\_ may be associated with tendinopathy
Rotator cuff tears
79
What are 5 clinical features of rotator cuff tears?
1. Pain with overhead activity (e.g. throwing, putting shirt on/off
2. Painful arc ~70-120o abduction
3. Pain when sleeping on affected shoulder
4. Tender over tendon or insertion (supraspinatus, infraspinatus)
5. Pain +/- weakness with static muscle testing
80
What are 3 features of rotator cuff tendinopathy (pathology) in the subjective examination?
1. Pain typically over the lateral upper arm
2. Pain with overhead activity (e.g. throwing, shirt on/off, washing hair)
3. Minimal pain at rest
81
What are 3 features of rotator cuff tear(pathology) in the subjective examination?
1. Pain typically over the lateral upper arm
2. Pain with overhead activity (e.g. throwing, shirt on/off, washing hair)
3. Pain sleeping on affected shoulder – compression of rotator cuff tendons
4. Minimal pain at rest
82
Can be hard to differentiate between a rotator cuff tendinopathy and tear. When to refer for imaging?
Have to ask the questions: "Will it change my management for patient?"
83
What are 7 findings in the physical examination for a rotator cuff pathology?
1. Painful arc in abduction (~70-120o)
2. AROM vs. PROM
3. Tender over tendon or insertion
4. Pain +/- weakness with static muscle testing (abduction, IR, ER), especially if tear – will help to determine which component of RC
5. Positive impingement tests (if supraspinatus)
* **Neer’s** – positive test (pain reproduction) – impingement subacromial structures
* **Hawkins Kennedy** – positive test (pain reproduction) – impingement subacromial structures
6. May have positive rotator cuff tests
* **Empty can** – positive test (pain or weakness) – supraspinatus
* **Gerber’s lift off test** – positive test (pain or weakness) – subscapularis
7. Differentiate: biceps involvement, ACJ, bursitis
84
What are the best combinations (3 special tests) to diagnose a subacromial impingement?
1. Positive Hawkins Kennedy
2. Positive painful arc sign
3. Weakness in ER (in 0o abduction)
85
What are the best combinations (3 special tests) to diagnose a full-thickness rotator cuff tear?
1. Positive painful arc sign
2. Drop-arm sign
3. Weakness in ER (in 0˚ abduction)
86
What does GIRD stand for?
Pathological Glenohumeral IR Deficit
87
What is GIRD?
Posterior shoulder stiffness – capsular tightness & muscular contraction
88
When is GIRD an adaption?
Common adaptation in dominant limb of overhead athletes (Throwing)
89
What is the mechanism of injury/cause of GIRD?
Cumulative loads on posterior shoulder during deceleration phase of throwing results in microtrauma and scarring of the posterior capsule and musculature = capsule gets tight
90
What is the risk of having GIRD?
Increased risk of internal & subacromial impingement – abnormal anterior humeral head translation
91
What are 2 clinical features of GIRD?
1. decreased GH cross-body adduction
2. IR ROM (25o less than unaffected limb at 90˚ abd)
Usually unilateral (will see on one side but not other)
92
What are the 2 features of GIRD in the subjective examination?
1. Pain/tightness posterior shoulder
2. May report impingement symptoms, anterior instability, labral symptoms
93
What are the 2 features of GIRD in the physical examination?
1. Decreased IR ROM (25o less than unaffected limb at 90˚ abd) – need to measure total rotation ROM; may have increased ER ROM
2. Decreased horizontal adduction
94
What are the 3 categories of Long head of biceps (LHB) pathology?
1. LHB inflammatory / degenerative conditions & partial tears
2. Instability of LHB tendon in bicipital groove (injury to transverse humeral ligament)
3. SLAP lesions
95
What is the mechanism of injury for Long head of biceps (LHB) pathology?
repetitive overhead activity
96
What are 2 features of LHB pathology in the subjective examination?
1. Pain directly over the LHB tendon
2. May complain of flicking of LHB tendon in/out of bicipital groove (if transverse ligament injury)
97
What are 2 features of LHB pathology in the physical examination?
1. Tender on palpation of LHB tendon +/- transverse ligament
2. Shoulder special tests:
* **Speed’s test** – positive test (reproduction or pain and/or weakness) – LHB tendinopathy or SLAP lesion
* **Yergason’s test** – positive test (reproduction of pain and/or subluxation of LHB tendon) – transverse ligament injury / LHB tendon instability or SLAP lesion
98
What are 2 special tests for LHB pathology?
1. Speed’s test – positive test (reproduction or pain and/or weakness) – LHB tendinopathy or SLAP lesion
2. Yergason’s test – positive test (reproduction of pain and/or subluxation of LHB tendon) – transverse ligament injury / LHB tendon instability or SLAP lesion
99
What is Adhesive capsulitis- "Frozen shoulder"?
* Spontaneous shoulder stiffness
* Multiregional synovitis/inflammation; capsuloligamentous fibrosis & contracture
100
What age, gender, population and side is more commonly affected by Adhesive capsulitis (Frozen shoulder)?
* Commonly age 40-60 years
* females \> males
* More common in people with diabetes; association with thyroid disorders & medications
* Typically non-dominant shoulder
101
What are the 4 phases of adhesive capsulitis (frozen shoulder)?
1. Sharp pain at EOR, achy pain at rest, sleep disturbances
2. Freezing – severe pain; early loss of ER is hallmark sign (DDx subacromial impingement)- Becoming stiff
3. Frozen – pain & loss of ROM- Stiff
4. Thawing – resolving pain; significant persistent stiffness
102
What is a clinical feature of Adhesive capsulitus (Frozen shoulder)?
Marked restriction of active & passive ROM (\>=25%) in at least 2 planes (esp. abduction & ER)
103
What are 5 features of Adhesove capsulitus (Frozen shoulder) in the subjective examination?
1. Need to ensure you ask enough questions to ascertain how symptoms began and progressed
2. What are their current symptoms? – how does this fit the stage of pathology?
3. Age and gender – commonly age 40-60 years; females \> males
4. Comorbidities – diabetes, thyroid dysfunction
5. Sleep disturbances:
* Typically worse in freezing (early) stage, eases into frozen stage (Loss of ER)
104
What are 3 findings of Stage 1/2 of Adhesive capsulitis (frozen shoulder) in the physical examination?
1. Early loss of ER
2. Lots of tests are painful – findings non-specific
3. Early freezing may have some increased PROM
105
What are 5 findings of Stage 3/4 of Adhesive capsulitis (frozen shoulder) in the physical examination?
1. Marked restriction of active and passive ROM (\>=25%) in at least 2 planes (especially abduction & ER)
2. AROM = PROM
3. Capsular pattern of restriction – ER\>abd\>IR
4. Capsular tests
* No inferior slide of the humeral head in passive abduction
* All accessory glides restricted – no inferior glide in abduction (inferior capsule adhered); inferior glide limited
5. Scapula dyskinesia – altered rhythm due to lack of GHJ movement (Might be compensating)
106
What are 3 things you need to differentiate between compared to adhesove capsulitis in the physical examination?
1. Rotator cuff arthropathy – clearly different history
2. GHJ arthritis – clearly different history
3. Acute bursitis
* Difficult to differentiate at the start of the first stage (freezing)
* Progressive nature of capsulitis
* Recognisable pattern of ER and hand behind back restriction
* US findings (bursa vs. synovium)
* Adhesive capsulitis has greater chance of also affecting other shoulder
107
Impingement is cluster of \_\_\_\_\_, rather than a pathology or diagnosis
symptoms
108
What are 7 shoulder impingement symptoms?
1. Rotator cuff pathology
2. Scapular dyskinesis
3. Shoulder instability
4. Biceps pathology
5. SLAP lesions
6. GIRD
7. Thoracic posture and mobility
109
What are the 2 impingement classifications?
1. By site of encroachment… anterosuperior vs. posterosuperior
2. By cause of impingement… primary vs. secondary
110
What is a Posterosuperior glenoid impingement?
1. Encroachment of rotator cuff tendons (esp. supraspinatus & infraspinatus) between greater tubercle of humerus and posterosuperior rim of glenoid
2. Esp. when humeral shaft extends beyond the plane of the body of the scapula (e.g. when scapula fails to retract)
111
What are the clinical features of a Posterosuperior glenoid impingement?
Pain during late cocking position of throwing (max ER, horizontal abduction +/- elevation [depending on sport])
112
What are 2 findings of a posterosuperior glenoid impingement in the subjective examination?
1. Typically a throwing athlete
* Pain during cocking phase of throwing (abduction/ER)
2. Also occurs in non-throwers – need to exclude instability
113
What are 4 findings of a posterosuperior glenoid impingement in the physical examination?
1. Anterior humeral head position
2. Tight posterior structures (capsule, muscles)
* Posterior capsule test
* Muscle length tests
3. Tender on palpation of posterior shoulder
4. Differentiate:
* Posterior cuff symptoms/spasm associated with other pathology
* Acute bursitis with posterior shoulder pain
* Referred pain to posterior shoulder
114
What is a subacromial impingement?
Mechanical encroachment of soft tissues in the subacromial space between the humeral head and acromial arch (e.g. bursa, rotator cuff tendons)
115
The _____ impingement sounds very similar to rotator cuff (esp. supraspinatus tear…etc)
subacromial impingement
116
What are 3 clinical features of a subacromial impingement?
1. Pain during mid-range of movement – painful arc during abduction
2. Pain typically on lateral arm (near deltoid insertion)
3. Night pain (lying on affected side)- Close down subacromial space
117
What is the cause of a primary cause of impingement? What is an example?
* Pain caused by **structural** narrowing of the subacromial space
* e.g. acromioclavicular arthropathy, type II or III acromion, subacromial bone spurs, swelling of soft tissues in subacromial space (bursa, RC tendons)
* Bony structural abnormalities could be due to congenital abnormality (e.g. os acromiale), osteophyte formation, acromial shape … BUT abnormalities are not always associated with clinical symptoms
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What is the cause of a secondary impingement? What are 3 examples?
* No structural obstructions (physical)
* Pain caused by **functional** problems in specific positions
* e.g. rotator cuff weakness, instability, scapular dyskinesis
* Example: RC dysfunction may result in impaired ability to prevent superior humeral head movement during elevation - impingement
* Example: lack of scapular upward rotation, posterior tilt and external rotation during arm elevation may result in lack of clearing of the acromial arch or glenoid rim - impingement
* Example: excessive anterior humeral head translation (due to capsule laxity and/or instability) results in narrowing of subacromial space during movement - impingement
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What are 4 characteristics of rotator cuff:
1. transverse force couple with subscapularis (to control anterior translation)
2. externally rotate GHJ
3. resist superior and anterior humeral head translation
4. depress the humeral head (with latissimus dorsi) – may be important to prevent impingement
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What are 3 characteristics of lowe trapezius and serrtus anterior?
1. produce posterior tilt, ER & upward
2. rotation of the scapula
3. prevent winging of the scapula
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Important role of physiotherapy in managing patients with secondary impingement – rehabilitation can address deficits that cause \_\_\_\_\_.
pain
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What are 3 subacromial (external) impingement symptoms?
1. Pain during mid-range of movement – painful arc during abduction
2. Pain typically on lateral arm (near deltoid insertion)
3. Night pain (lying on affected side)
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What are 2 posterosuperior glenoid (internal) impingement symptoms?
1. Posterior shoulder pain
2. Pain during late cocking position of throwing (max ER, horizontal abduction +/- elevation [depending on sport])
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What is the flow chart for an impingement symptoms?
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What are 6 characteristics of the normal resting position of the scapula?
1. Sits between T2 & T7
2. Flat against thoracic spine
3. Anterior tilt ~5-8˚
4. 30-45˚ anterior to the coronal plane (scaption)
5. Glenoid fossa is ~7˚ retroverted
6. relative to the scapula, 5˚ upward tilt
7. Asymmetry is normal… but may not be ideal
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What are 5 characteristics of scpulohumeral rhythm during elevation (flexion, abduction)?
1. ~120o movement at the GHJ
2. ~60o movement at the ACJ and SCJ (i.e. scapular movement)
3. Humeral head is stabilised in the glenoid against upward translation by deltoid
* by transverse force couple (infraspinatus/teres minor + subscapularis)
4. Minimal scapular elevation (Relatively depressed rather upwards rotation)
5. No winging; smooth movement
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What is dyskinesis?
impaired ability to control movement – e.g. lack of coordination
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What are the 5 consequences of scapula dyskinesis?
1. Changed relationship between glenoid and humerus
2. Decreased width of subacromial space (Can lead to impingement)
3. Alters the fulcrum of the humeral head into the glenoid fossa
4. Alters the length tension relationship of the rotator cuff muscles (possibly leading to instability)
5. May interrupt kinetic chain e.g. during throwing (scapula is key link between trunk and arm – energy transfer from lower limbs to arm)
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What are the 4 typical deviations of scapula dyskinesis?
1. lack of scapular upward rotation, posterior tilting & external rotation
2. increased clavicular elevation and retraction
3. Scapular asymmetry at rest of during movement (abnormal scapulohumeral rhythm)
4. Winging of the medial border (Due to serratus anterior) or inferior angle (Lower trapezius)
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What are 3 muscle impairments in scapular dyskinesis?
1. Decreased strength of serratus anterior
* Results in winging of medial border of scapula
2. Hyperactivity and early activation of upper trapezius
* Results in excessive elevation of the shoulder girdle during elevation
3. Decreased activity and late activation of the middle and lower trapezius
* Results in winging of inferior border of scapula
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What are 2 soft tissues findings in scapular dyskinesis?
1. Tight pectoralis minor
* Results in increased scapular internal rotation and increased anterior tilt
* Pec minor length test
2. Posterior GHJ capsular stiffness
* Posterior capsule length test
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What are the 3 features of scapula dyskinesis in the physical examination?
1. Remember that asymmetry between limbs is common
2. Visual inspection of scapular position at rest and during dynamic humeral movements (including under load)
3. Objective measurements of scapular position
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What are 2 types of scapular corrective manoeuvres for scapular dyskinesis in the physical examination?
1. Scapula assistance test (SAT)
2. Scapula retraction test (SRT)
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What are 2 characteristics of the scapula assistance test (SAT) for scapular dyskinesis in the physical examination?
1. Manual assistance of correct scapular movement during arm elevation
2. If pain is reduced during SAT (compared to non-assisted movement), indicates scapular involvement in shoulder problem
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What are 3 characteristics of the scapula retraction test (SRT) for scapular dyskinesis in the physical examination?
1. Test of scapular stability
2. Patient performs elevation or empty can test while physio stabilises the scapula and shoulder (In a retracted/neutral position)
3. Positive for scapular involvement if initial pain during elevation or empty can test disappears during SRT
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The diagnostic value is ____ (high/low) for symptom modification tests.
low
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What does SSMP stand for?
Shoulder symptom modification procedure
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What are 4 characteristics of SSMP (treatment direction test)? What are 3 examples?
1. Useful given the limited diagnostic utility of many shoulder tests – adjunct to help support clinical decision making (Help guide treatment but not diagnostic)
2. Identify the movement or activity that reproduces shoulder symptoms, and apply the SSMP
3. Series of mechanical techniques are applied while the patient performs the movement or activity that most closely resembles their symptoms
4. Techniques can be applied to different parts of the kinetic chain:
* Start locally at the shoulder; scapula; thoracic and cervical spine, posture; lumbar spine; lower extremities
* Anywhere that is a potential source of pain
Examples of modifications:
1. Postural correction (e.g. sitting, standing, kyphosis)
2. Ensure correct muscle contraction (e.g. scapular correction, core stability)
3. Mechanically correct kinematics (e.g. apply posterior glide to humeral head)
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What are 3 principles in the SSMP (treatment direction test)?
1. Define a position or movement that causes the symptoms, based on the physical examination
2. Correct the possible cause of the symptoms, based on biomechanics or arthrokinematics
3. Observe possible change in symptoms
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What is the head of humserus position?
Humeral head should sit ~1/3 anterior to acromion
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What are 3 results if the humeral head is sitting more anteriorly?
1. ⁃ Is there capsuloligamentous instability in the anterior shoulder (traumatic instability, MDI)?
* assess capsuloligamentous structures
* assess labrum
2. Is there restriction of posterior shoulder structures (cuff, capsule, both)?
* assess posterior structures - horizontal adduction; posterior capsule length test; GIRD; AP glides of HH
3. Is the scapular sitting in anterior/downward tilt?
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What are the 2 characteristics of motor control for head of humerus position?
1. Assess patient’s ability to control the humeral head within the glenoid
* Role of the transverse force couple
2. Assess the capacity of the subscapularis (especially in people with anterior instability)
* Subscapularis is an IR, depresses and anteriorly translates humeral head
* Anterior component of GH transverse force couple
* In people with instability, subscapularis may be slow/sluggish or switch off during movement
3. Test this:
* Fingers in armpit, 90o abduction (or functional position)
* Isometric, concentric and eccentric ER (under low load)
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What do 3 TDTs (SSMP) look like?
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What are 2 interpretation of assessment findings of AROM elevation?
1. Full AROM?
2. Pain through range or at EOR?
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What are 2 interpretation of assessment findings if reduced AROM elevation?
1. Is PROM also limited?
2. Pain limitation vs. weakness?
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What is an interpretation of assessment findings of external rotation loss?
Pattern for adhesive capsulitis
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What are 2 interpretations of assessment findings of crepitus?
1. Osteoarthritis?
2. Fracture (e.g. distal clavicle)?
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What are 3 interpretations of assessment findings of mid-range pain?
1. MDI?
2. What happens when sensitise with cervical mvt?
3. Somatic referral? Neural tissues?
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What is an interpretation of assessment findings of Scapula dyskinesia or abnormal humeral head position?
If significant improvement with TDT/SSMP –implications for treatment
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What are 3 passive movement restrictions for the shoulder?
1. Joint restriction e.g. GHJ restriction - will influence scapula pattern
2. Insufficient soft tissue flexibility e.g. posterior capsule/ligament tightness, posterior RC tightness, pec minor tightness - will influence scapula & GHJ movement, may also affect ACJ movement
3. Differentiate capsular/ligamentous vs. muscle tightness
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What are 3 active movement restrictions for the shoulder?
1. Overactivity (vs. tightness) – protective, pain, pattern (maladaptive or adaptive)
2. Poor recruitment – e.g. scapular stabilisers during bicep curl or carrying load
3. Inadequate control – e.g. insufficient strength
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What are the assessment features of capsular tightness?
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What are 3 assessment features of posterior capsular tightness (vs posterior shoulder tightness)?
1. Restricted IR, horizontal adduction and flexion – moving **forward**
2. Restricted posterior glide
3. Humeral head may sit anteriorly
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What are 3 assessment features of anterior capsular tightness?
1. Restricted abduction, ER, extension and horizontal abduction – moving **backward and outward**
2. Restricted anterior glide, or posterior glide
3. Humeral head may sit also sit anteriorly (capsule pulls HH forward), or superiorly if anteroinferior capsule is tight
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What are 3 assessment features of inferior capsular tightness?
1. Restricted abduction – moving **upward/outward**
2. Restricted inferior glide
3. Humeral head may sit superiorly (Decrease subacromial space --\> possible impingement)
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Patient interview and physical examination give key information to
guide \_\_\_\_\_\_\_of patients with shoulder conditions … important to tailor your physical examination based on your primary hypothesis and differential diagnoses (from interview). Different shoulder conditions have different _____ features
management; presenting
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Many special tests of the shoulder, often with _____ (high/low) diagnostic utility … combinations of tests more informative … treatment direction test may help guide management
low
