L5 Shoulder Evaluation Flashcards
What informs your clinical reasoning?
- Progression and/or stage of S/S
- stability of condition
- presence of preexisiting conditions
- presenting impairments and how they relate to functional limitations
- patients current overall level of functioning
- patients personal factors
Articular Injuries
glenohumeral OA, inflammatory arthritis
instability
labral tear
Periarticular Injuries
calcific tendinitis
adhesive capsulitis
biceps tendinitis
AC joint arthritis
AC joint sprains
RC pathology
Osseous Injuries
proximal humerus or clavicle fracture
bone cysts
infections
tumors
Referred pain
cervical radiculitis and arthritis myofascial neck pain
cardiac, splenic, hepatic, diaphragmatic etiologies
Biomechanical pain
scapular dyskinesia w/o structural pathology, repetitive motion resulting in fatigue
Capsular pattern
inflammation such as rheumatoid, spetic, gout, traumatic arthritis or capsulitis, OA
Non-capsular pattern
present when non-capsular factors cause the decreased range. Bursitis, loose body in the joint, joint sublixation
Capsular pattern of GHJ
Capsular pattern of GHJ is ER most limited followed by abduction and IR
determine capsular pattern by performing full PROM at end range
Subacromial impingement movement pattern
abnormal movement patterns in patients w/shoulder pain is substantial
but you cannot prove causation
Which special tests provide clinicians with the most value when examining the shoulder?
combinations of shoulder physical exam tests provide better accuracy, but marginally so
support for stressing a comprehensive clinical exam including hx and physical examination
combine 2-3 tests of opposing sensitivity and specificity
Diagnosis is
the process and end result of information obtained in the exam and eval
you have to exam to arrive at initial hypothesis and then eval to weigh all your data
Diagnostic gold standard for shoulder conditions
SLAP: MRA
GHJ OA: clinical and imaging
Frozen: clinical
RC Tears: MRI and US
Prognosis
the process of determining the level of optimal improvement that may be obtained from intervention, and how long to reach that goal
Plan of Care
specific interventions to be used and the proposed duration and frequency of interventions taht are required to reach teh anticipated goals and outcomes
General factors that influence prognosis and outcomes
patients health status, risk factors, respose
needs and goals
natural history
complexity, severity, acuity
personal and environmental factors
Prognostic Factors for Shoulder Pain
longer duration of symptms
gradual onset of symptoms
high pain intensity
45-54 years of age
catastrophizing
Shoulder pain and the workplace
very common, most likely not caused by work
many cases no cause is found
managing shoulder pain should be a biopsychosocial model, to help them to return to work sooner
Natural history of asymptomatic full thickness tears
- present in individuals in their 60s and 80s
- Common, increased incidence with aging
- Develop symptoms 2-3 years
- Larger tears are more likely to develop symptoms
Natural History of RCT Symptomatic
- Progress in tear size in an avg of 2 years
- Size progression is correlated with increasing symptoms
- Small full thickness tears have a lower risk of progression
- partial thickness progress slower than full thickness tears
Re-tears of RC after surgery
RC repairs have a 20-90% of re-tears
best predictor of rotator cuff integrity post op was preoperative tear size
tears over 6 cm are less likely to heal completely
Predictors for positive outcomes, RCT
younger age (younger than 55)
smaller tear size (1-2 cm)
shorter symptom duration
absence of worker comp
worse preop status was associated with greater improvement
Low Risk for irreversible change RCT
intact RC or small partial thickness tears
At Risk for irreversible change RCT
<65 yo, symptomatic full thickness, acute tear of any size, tears with loss of function
Irreversible changes have occurred group RCT
large (3-5 cm), chronic tears or >70
Absolute indications for surgical repair of RCT
onset of acute, post trauma weakness in younger active individuals
Relative indications for RCT surgery
pain or weakness that has been refractory to an appropriate course of non-operative management
Non-operative treatment for RCT
patients w/tendonitis, partial thickness, small full thickness, chronic tears in older, all large irreparable tears
Prognosis for GHJ Instability
70-100% recurrence rate in pts younger than 20
immobilization is not indicated for younger pops
older pts may have RCT, fracture, neuro deficit
Surgery is not indicated in GHJ instability for
patients with low physical demands greater than 20
asymptomatic in ADLs
RF for Reinjury after Bankart Repair
age <22 years old
male
number of preop dislocations
participation in sports
loss of glenoid or humeral bone
presence of anterior avulsion
Surgery for GHJ instability
young adults engaged in high demand sports who have had their first acute dislocation
no evidence for those not within those categories
Patients with dislocation do not need
mobilization
Secondary impingement and tensile overload due to underlying instability do not need
GHJ mobs
Grade 2+ posterior translation do not need
posterior glides to increase IR
Subacromial impingement interventions
eccentric exercises for RC and concentric for scapula stabilizers reduces pain and improves function
Potential Controversies
Will surgery benefit the patient
could surgery make it worse
does the patient believe PT as a viable intervention
