MSK/Rheumatology - Upper Extremity I - Exam 3 Flashcards
What are the four muscles of the rotator cuff?
- Supraspinatus
- Infraspinatus
- Teres Minor
- Subscapularis
SITS
Which rotator cuff muscles perform external rotation and abduction?
- Supraspinatus
- Infraspinatus
- Teres Minor
SIT
Which rotator cuff muscles perform internal rotation?
Subscapularis
Which rotator cuff muscle is most commonly involved in an injury?
Supraspinatous
Which is the clinical presentation of a rotator cuff injury?
- Pain over anterior and lateral shoulder
- Decreased ROM and inability to abduct arm above shoulder level
- Shoulder may catch
What is the difference between tendonosis and tendonitis?
Tendonosis: Chronic degeneration of muscle typically with age
Tendonitis: Inflammation associated with repetitive trauma/everyday use of shoulder
What can cause a chronic tear of the rotator cuff?
- Degeneration
- Impingement
- Overload
What can cause an acute tear of the rotator cuff?
When would you suspect an acute tear?
- Trauma
- Suspicion with acute shoulder pain with negative radiographs
What is the clinical presentation of tendonitis/impingement of the rotator cuff?
- Patient does repetitive overhead activity
- Pain comes on gradually
- Deep ache in lateral shoulder that radiates to deltoid
- Point tenderness
- ROM painful > 90 degrees, but improves with analgesics
What specialized exams assess for impingement of the rotator cuff?
What are you looking for?
Neer’s and Hawkin’s
Looking for pain
What is the clinical presentation of a chronic rotator cuff tear?
- Male over 40
- Pain worse with overhead activities and at night
- Pain is followed by gradual weakness
- Decreased ability to move arm, especially abduction
- Restricted ADL’s >90 degrees
What specialized exams could you perform to assess for a chronic rotator cuff tear?
What are you looking for?
Drop arm and Empty Can
Looking for weakness
What is found on physical exam in a rotator cuff tear?
- Muscle weakness is hallmark (abduction and external rotation)
- Weakness does not improve with analgesics
- Cannot lift 2-5 pounds overhead’
- May have atrophy in large tears
What are some diagnostic studies that you can perform to distinguish between rotator cuff tendinopathy and a tear?
- Lidocaine injection test
- Radiographs
- MSK U/S
- MRI
What are the acute treatment options for a rotator cuff tear?
What about for persistent rotator cuff tear symptoms?
Acute:
- Ice, NSAIDs
- Weight pendulum stretching
- Short term immobilization
- Restrict overhead positioning
Persistent:
- Subacromial steroid injections (no more than 3-4 injections per year)
- Surgery (arthoscopic repair vs joint arthoplasty)
What is the principle cause of rotator cuff tendonitis?
Shoulder impingement syndrome
What is the clinical presentation of shoulder impingement?
- Nearly identical to rotator cuff tendonitis
- Subacromial tenderness
- Normal glenohumeral joint ROM (pain at >90 degrees)
- Preserved strength
What is the hallmark physical exam finding of shoulder impingement?
Pain reproduced by the painful arc of flexion-internal rotation maneuvers (Neer’s and Hawkin’s)
Pain of the shoulder at 45 degrees or below indicates what degree of impingement? What about at 60-70 degrees?
- Severe (45 or below)
- Moderate (60-70)
What is the treatment for shoulder impingement?
- Ice, NSAIDs, activity modification
- NO arm sling
- Physical Therapy referral
- Follow up 2-3 weeks later to confirm improvement in symptoms
- May have benefit from steroid injections if persistent
- Surgery if symptoms are severe and anatomic variant could be improved
What is the MOI for a labral tear?
- FOOSH or sudden pull
- Repetitive overuse (throwing athletes, laborer)
What is the clinical presentation of a labral tear?
- Pain if acute
- Clicking/catching if chronic
- Frequently associated with other shoulder pathology
What is typically observed on physical exam in a labral tear?
- Biceps tendon pain
- Restricted internal/external rotation of the glenohumeral joint
- Motion dysfunction of the scapula
- Positive Anterior Glide, Speed’s, O’Brien’s test
What imaging can be done for a labral tear?
- Radiographs (initial)
- MRA > MRI
- Arthoscopy for definitive diagnosis
What is the preferred treatment for a labral tear?
- Nonsurgical
- NSAIDs and PT
How is adhesive capulitis diagnosed?
- ROM tests confirm reduced ROM at glenohumeral joint in 2 or more planes (passive and active) (Positive Apley Scratch Test)
- Severe pain
- Loss of ROM is a mechanical restriction, not pain restriction
- Abduction/External rotation most common
What is the treatment for adhesive capsulitis?
- Consult Physical Therapy
- Most cases are self limited
- Conservative treatment
What is the MOI for an acromioclavicular injury?
Fall onto the tip of the shoulder with arm tucked into the side
How does a patient typically present with an acromioclavicular injury?
Bump on the shoulder that is worse at bedtime
What is typical on the physical exam of a patient with an AC sprain?
- AC joint swelling and possible deformity
- AC joint tenderness
- Pain aggravated with downward traction
- Pain with passive cross-body adduction (Cross-Over Test)
In a Grade I AC injury, is there any tear/separation?
What is seen on imaging?
There is pain, but no separation.
Radiographs will be normal
In a Grade II AC injury, is there any tear/separation?
What is seen on imaging?
There is separation of the Acromioclavicular (AC) ligament (partial separation).
Radiographs show slight widening and offset at the clavicle.
In a Grade III AC injury, is there any tear/separation?
What is seen on imaging?
There is separation of the Acromioclavicular (AC) AND Coracoclavicular (CC) ligaments.
Radiographs show distal clavicle at or above the superior margin of the acromion.
What is the treatment for an AC sprain?
- Shoulder immobilizer for 3-4 weeks
- Restriction of overhead, reaching, and weights
- Ice, rest, NSAIDs, and steroid injections if not improving after 2-4 weeks
- Surgical consideration for Grade III
Where do most clavicular fractures occur?
In the middle 1/3 of the clavicle
Which clavicular fracture location should you evaluate for internal organ involvement and refer to a specialist?
Proximal 1/3 (least common)
What is the clinical presentation of a clavicular fracture?
- Visual deformity
- Tenderness
- Decreased ROM
What imaging is appropriate to obtain for a clavicular fracture?
Single AP radiograph of the clavicle
What is the treatment for a clavicular fracture?
Conservative treatment for non-displaced, minimally displaced, or pediatric patients
- Sling vs figure of 8 harness
- Analgesics, muscle relaxers
- Sleep upright
Ortho Referral:
- Displaced mid clavicle fracture and all proximal and distal 1/3 fractures
- Surgery
What can cause subacromial bursitis?
- Repetitive movement
- May result from systemic disease (RA, gout, sepsis)
What is the clinical presentation of subacromial bursitis?
- Pain with ROM and rest
- Localized tenderness to palpation
- May be associated with rotator cuff tendonitis
- May cause impingement syndrome
What is the treatment for subacromial bursitis?
- Ice and NSAIDs
- Restriction of overuse
- Aspiration and Steroid injection (do not do injection if you suspect sepsis or aspirate)
What is the clinical presentation of biceps tendonitis?
- Pain to anterior shoulder with abduction and external rotation
- Max point of tenderness along bicipital groove
- Popping sensation
- Weakness
- Positive Yergason’s, Speed’s
What can be seen on clinical presentation of an individual with a ruptured biceps tendon?
“Popeye Deformity”
What is the treatment of biceps tendonitis?
- NSAIDs and rest to reduce inflammation
- Physical therapy to help with strength and prevent rupture
- Surgery for ruptured tendon
