MSK #12- Shoulder conditions Flashcards
GH Subluxation and Dislocation: What direction do they typically occur in
- 95% anterior- inferior
- occurs when abducted UE is forcefully externally rotated causing tearing of inferior GH ligament, anterior capsule, and occasional glenoid labrum
GH Subluxation and Dislocation: Tell me about posterior dislocations
- rare
- occur w/ multi-directional laxity of GH joint
- occurs w/ horizontal adduction and IR of GH joint
GH Subluxation and Dislocation: possible complications
- compression Fx of posterior humeral head (Hill-Sachs lesion)
- superior labrum tear (SLAP lesion)
- avulsion of anteroinferior capsule and ligaments associated w/ glenoid rim (Bankart’s lesion)
- bruising of axillary nerve
GH Subluxation and Dislocation: what position should pt.s avoid after surgical repair for chronic dislocation/subluxation
the apprehension position- flexion 90 degrees or more, horizontal abduction 90 degrees or more, and ER to 80 degrees
GH Subluxation and Dislocation: diagnostic and special tests
- Apprehension test
- X-ray
- CT scan
- MRI
GH Subluxation and Dislocation: med
acetaminophen for pain
NSAIDs for pain and/or inflammation
GH Subluxation and Dislocation: priorities for PT
- may varying depending on pt. problems and if there was a surgical intervention
- biomechanical faults caused by joint restrictions should be corrected w/ joint mobs to the specific restrictions identified during exam
- restoration of normal shoulder mechanics: strengthening, endurance, coordination
- ther ex should focus on regaining dynamic scap/thoracic , GH stabilization, and muscle re-ed
Instability: 2 categories
Traumatic- common in young throwing athletes
Atraumatic- pt.s w/ congenitally loose connective tissue around the shoulder, Typically ages 10-35. No Hx of trauma.
Instability: characterized by ____
- popping/clicking
- repeated dislocation/subluxation
- anterior or posterior pain
- pain and instability w/ activity
Instability: when is surgery indicated
- labrum repair
- Bankart lesions
Instability: how is it diagnosed
- clinical exam of Hx, AROM, PROM, resistive tests, palpation
- Will have full or excessive ROM
- palpation and muscles tests likely to be normal
- Special tests: Load and shift test, apprehension test, relocation test, augmentation test
- MRIs identify labral tears
Instability: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Instability: priorities for PT
- emphasize return of function w/o pain
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
- For pt.s requiring surgery, shoulder is kept in sling for 3-4 weeks. After 6 weeks more sports-specific training can be done. Full return may take 3-4 months
Labral Tears: two major types
SLAP- tear on top half and may involve biceps tendon
Bankart- tear on bottom half and commonly involve the inferior glenohumeral ligament. Often occurs w/ other shoulder injuries such as dislocations
Labral Tears: s/s
- shoulder pain that cannot be localized to a specific point
- pain worse w/ overhead activities or when arm is held behind back
- weakness
- instability in shoulder
- pain w/ resisted biceps flexion
- tenderness over front of shoulder
Labral Tears: when is surgery required
- unstable injuries required to reattach labrum to glenoid
- Bankart lesion
Labral Tears: diagnostic tests
- clinical exam: Hx, AROM, PROM, resistive tests, palpation
- MRI
- arthroscopic surgery (gold standard)
Labral Tears: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Labral Tears: priorities for PT
- emphasize return of function w/o pain
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
- For pt.s requiring surgery, shoulder is kept in sling for 3-4 weeks. After 6 weeks more sports-specific training can be done. Full return may take 3-4 months
Thoracic Outlet Syndrome (TOS): what is it
- compression of neurovascular bundle (brachial plexus, subclavian artery and vein, vagus and phrenic nerves, and sympathetic trunk) in thoracic outlet between bony and soft tissue structures
- occurs when size or shape of thoracic outlet is altered
Thoracic Outlet Syndrome (TOS): common areas of compression
- superior thoracic outlet
- scalene triangle
- between clavicle and first rib
- between pec minor and thoracic wall
Thoracic Outlet Syndrome (TOS): what type of surgical intervention may be used
removal of cervical rib or a release of anterior and/or middle scalene muscle
Thoracic Outlet Syndrome (TOS): Diagnostic tests
- x-ray: identify abnormal bony anatomy
- MRI: identify abnormal soft tissue anatomy
- electrodiagnostic test: assess nerve dysfunction
Thoracic Outlet Syndrome (TOS): Special Tests
- Adson’s test
- Roos test
- Wright test
- Costoclavicular test
Thoracic Outlet Syndrome (TOS): meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Thoracic Outlet Syndrome (TOS): priorities for PT
- interventions will vary depending on exact cause
- postural re-education
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
- manip (typically 1st rib articulation) to diminish pain and soft tissue guarding
AC and SC Joint Disorders: typical MOI
- fall onto shoulder w/ UE abducted
- collision w/ another person during a sporting event
AC and SC Joint Disorders: how is injury graded
- traditionally: 1st to 3rd degree
- Rockwood classification: grades I to IV
AC and SC Joint Disorders: UE positioning in acute phase
- UE positioned in neutral w/ use of sling
- avoid shoulder elevation during acute phase of healing
AC and SC Joint Disorders: diagnostic and special tests
- x-ray
- clinical exam
- Shear test
AC and SC Joint Disorders: surgical intervention
- very rare b/c it typically will lead to AC joint degeneration
AC and SC Joint Disorders: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
AC and SC Joint Disorders: priorities for PT
- emphasize return of function w/o pain
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- manual therapy to AC and SC joints and surrounding connective tissues sch as soft tissue/massage, joint oscillations, and mobs
Subacromial/Subdeltoid Bursitis: what is it
- subacromial and subdeltoid bursae (which may be continuous) have a close relationship to rotator cuff tendons, making them susceptible to overuse
- can also become impinged beneath the acromial arch
Subacromial/Subdeltoid Bursitis: diagnosis
clinical exam: Hx, AROM, PROM, resistive tests
Subacromial/Subdeltoid Bursitis: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Subacromial/Subdeltoid Bursitis: PT interventions
refer to general interventions for bursitis/tendonitis/tendonosis
Rotator Cuff Tendonosis/Tendonopathy: what is it
- tendons of RTC are susceptible to tendonitis, due to relatively poor blood supply near insertion of muscles
- results from mechanical impingement of the distal attachment of the RTC on the anterior acromion and/or coracoacromial ligament with repetitive overhead activities
Rotator Cuff Tendonosis/Tendonopathy: diagnostic tests and special tests
- possibly MRI, but sometimes not sensitive enough for accurate assessment
- Supraspinatus test
- Neer’s impingment test
Rotator Cuff Tendonosis/Tendonopathy: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Rotator Cuff Tendonosis/Tendonopathy: PT interventions
refer to general interventions for bursitis/tendonitis/tendonosis
Impingement Syndrome: what is it
characterized by soft tissue inflammation of the shoulder from impingement against the acromion with repetitive overhead AROM
Impingement Syndrome: diagnostic tests and special tests
- arthrogram
- MRI
- Neer’s impingement test
- Supraspinatus test
- Drop arm test
Impingement Syndrome: position to avoid if there is a surgical repair
avoid shoulder elevation above 90 degrees
Impingement Syndrome: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Impingement Syndrome: priorities for PT
- restoration of posture
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
Internal (posterior) Impingement: what is it
- characterized by an irritation between the RTC and greater tuberosity or posterior glenoid and labrum
- often seen in athletes performing overhead activities
- pain commonly noted on posterior shoulder
Internal (posterior) Impingement: diagnostic tests
- no specific diagnostic test
- determined through clinical exam
Internal (posterior) Impingement: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Internal (posterior) Impingement: priorities for PT
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
Bicipital Tendonosis/Tendonopathy: what is it
- most commonly an inflammation of the long head of the biceps
- results from mechanical impingement of the proximal tendon between the anterior acromion and the bicipital groove of the humerus
Bicipital Tendonosis/Tendonopathy: diagnostic tests and special tests
- possibly MRI, not always sensitive enough
- Speed’s test
Bicipital Tendonosis/Tendonopathy: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Bicipital Tendonosis/Tendonopathy: priorities for PT
refer to general interventions for bursitis/tendonitis/tendonosis
Proximal Humeral Fx: what is it
- humeral neck Fx frequently occur w/ a FOOSh among older osteoporotic women
- generally does not require immobilization or surgical repair since it is a fairly stable Fx
- greater tuberosity fx are more common in middle-age and elder adults, usually related to a fall onto the shoulder, and does not require immobilization for healing
Proximal Humeral Fx: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Proximal Humeral Fx: priorities for PT
- early PROM is important in preventing capsular adhesions
- emphasize return of function w/o pain
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
Adhesive Capsulitis: Common findings in Hx
- Age 45+
- onset is insidous, post-surgical, or due to trauma -
- common chronic disease: diabetes
- typically not painful unless stretched
Adhesive Capsulitis: what is it
- characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule, usually due to disuse following injury or repetitive microtrauma
- may be insidious onset
- Restriction follows capsular pattern: ER>abduction/flexion>IR
- may demonstrate shoulder hiking
Adhesive Capsulitis: meds
acetaminophen for pain
NSAIDs for pain and/or inflammation
Adhesive Capsulitis: priorities for PT
- emphasize return of function w/o pain
- functional training and restoration of muscle imbalances using ther ex to normalize strength, endurance, coordination, and flexibility
- correcting biomechanics w/ joint mobs
Name that Pathology
Symptoms: intermittent pain w/ overhead or strenuous activities, over age 35, could have night pain, scapular or RTC weakness
External Primary Impingement (stages 1-3)
Name that Pathology
Symptoms: classic night pain, weakness noted predominantly in abduction and lateral rotators, loss of motion
RTC tear (full-thickness)
Name that Pathology
Symptoms: inability to perform ADLs due to loss of motion, loss of motion may be perceived as weakness
Adhesive Capsulitis
Name that Pathology
Symptoms: apprehension to mechanical shifting limits activities, slipping, popping, sliding, apprehension w/ horizontal abduction and lateral rotation , may have anterior or posterior pain, weak scapular stabilizers
Anterior Instability (w/ or w/o external secondary impingement)
Name that Pathology
Symptoms: slipping or popping of humerus out the back- may be associated w/ forward flexion and medial rotation while shoulder is under a compressive load
Posterior Instability
Name that Pathology
Symptoms: looseness of shoulder in all directions- may be most pronounced while carrying luggage or turning over in sleep, may or may not have pain
Multidirectional instability
RTC Lesion/Tear: Hx
- typically age 30-50
- pain and weakness after eccentric load
RTC Lesion/Tear: Exam
- may observe shoulder hike
- weakness and pain with abduction and ER
- pain w/ PROM if there is also impingement
- Special Tests: drop arm test, empty can test
- tenderness around RTC
- may use xray
- MRI
