MSK - shoulder

Question 1

What are the most likely pathologies for the injury?

Answer 1

Subscapularis tear

Supraspinatus tear

Question 2

Briefly describe what subacromial pain syndrome is, its symptoms, its cause, and aggravations

Answer 2

Non-traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion.
Often present with:
- painful arc of pain
- pain after activity and early AM
- pain during ER and elevation
Pain is usually associated with a change in load to the tendon and often worsens during overhead activities and overuse

Question 3

Briefly describe what rotator cuff tendinopathy is, its symptoms, its cause, and aggravations

Answer 3

Indicates a problem with your shoulder muscles. It can be caused by an overload of the four muscles located in that region, or an inflammation of one of the tendons.
Often present with:
- painful arc of pain
- pain after activity and early AM
- pain during ER and elevation
Pain is usually associated with a change in load to the tendon and often worsens during overhead activities and overuse

Question 4

What would be included in a subjective history of the shoulder joint?

Answer 4

1. Onset
   - insidious/ trauma/ timescale
2. Pain behaviours
   - location, severity, 24-hour pattern, aggs and eases
3. Special questions
   - locking, red flags, previous dislocations
4. PMH and general health
   - THREADS

Question 5

How do glenohumeral joint related pains differ from acromioclavicular joint and sternoclavicular joint pain?

Answer 5

Glenohumeral joint pains = commonly felt over the anterior deltoid, often extending into the region of the distal deltoid and biceps
Acromioclavicular joint and sternoclavicular joint pain = often felt locally around the joint

Question 6

What special questions could you ask for the shoulder joint?

Answer 6

• Have you experienced problems with this area before?
• Any locking or catching?
• Persistent loss of ROM

Question 7

Give some red flags for the shoulder joint

Answer 7

• history of cancer
• sudden weight loss
• fracture
• dislocation
• history of heart attack
• sweating and chest pain when shoulder pain occurs
• jaw, mouth or teeth pain when shoulder hurts

Question 8

What would you look for in both the informal and formal observation?

Answer 8

Informal
 - observe how they use their arms, facial expressions and quality of movement
Formal 
 - observe in sitting and standing
 - skin colour changes
 - inspect muscle bulk for symmetry
 - head of humerus
 - elbow length - compare epicondyles

Question 9

What would you palpate during the objective assessment?

Answer 9

Temperature of area
Swelling and deformity
Bruising
Mobility and feel of soft tissue
Tenderness of bone
Clavicular space

Question 10

What part of the body must we clear first and how?

Answer 10

Clear the thoracic spine

• the patient sits with arms across the chest
• perform thoracic flexion, extension. side flexion, rotation and apply overpressure
• no pain reproduced = no pain in the thoracic spine

Question 11

Name and describe 2 tests for rotator cuff related shoulder pain

Answer 11

1. Neer test
   - begin in sitting position. stabilize scapula with one hand, internally rotate arm (pronation), maximum flexion with overpressure
   - pain reproduction is a positive test
2. Hawkins Kennedy test
   - begin in sitting position, 90degrees shoulder flexion, 90degrees elbow flexion, stabilize the scapula and hold elbow. Apply internal rotation (hand brought down)
   - pain reproduction is a positive test

Question 12

Name and describe 2 tests for RC tears

Answer 12

1. IR lag sign
   - hand of painful shoulder on the lumbar region, lift hand off back passively to full IR and ask the patient to maintain position.
   - positive test = hand moves towards the back, subscapularis tear
2. Drop arm test
   - 90degrees arm abduction, ask the patient to lower smoothly
   - positive test = sudden drop or weakness during lowering, supraspinatus tear

Question 13

Name the 4 rotator cuff muscles.

Answer 13

Subscapularis
Supraspinatus
Infraspinatus
Teres minor

Question 14

Name the origin, insertion, and action of the subscapularis

Answer 14

Origin: subscapular fossa of scapula
Insertion: lesser tubercle of the humerus
Action: rotates the arm medially

Question 15

Name the origin, insertion, and action of the supraspinatus

Answer 15

Origin: supraspinous fossa of scapula
Insertion: superior part of the greater tubercle of the humerus
Action: initiates abduction of the arm

Question 16

Name the origin, insertion, and action of the infraspinatus

Answer 16

Origin: infraspinous fossa of scapula
Insertion: inferior part of the greater tubercle of the humerus
Action: rotates arm laterally

Question 17

Name the origin, insertion, and action of the teres minor

Answer 17

Origin: posterior surface of the scapula, adjacent to its lateral border
Insertion: greater tubercle of the humerus, inferior to infraspinatous
Action: rotates arm laterally

Question 18

What exercises would you recommend?

Answer 18

Isometric external rotation - strengthens muscle without moving it and risking pain/ further injury (can be done at work
Rows - sitting position with knees slightly bent, wrap a resistance band around feet and hold each end. Pull the band back, like rowing
Bear hugs - stretches rotator cuff muscles. Place a resistance band around back, holding each end, with thumbs pointed up. Bring your arms out and forward, to give a big hug

Question 19

What test can be used for subacromial impingement?

Answer 19

The Painful Arc Test is considered positive for supraspinatus impingement if the patient reports pain between 60 degrees and 120 degrees of abduction. Pain should reduce after 120 degrees of abduction. If the patient instead reports pain at the end of abduction, acromioclavicular joint dysfunction is indicated.