MSK - the shoulder Flashcards
What are some common arthrogenic, myogenic and neurogenic hypotheses?
Arthrogenic: - OA/RA - Adhesive capsulitis Myogenic: - Subacromial shoulder pain - Rotator cuff tear - Dislocation shoulder instability Neurogenic: - Cervical radiculopathy
Give the assessment of early and advanced OA
Early stage: - complain of mild pain - progressive, activity-related pain - pain described as deep Advanced stages: - loss of AROM and PROM - joint may appear enlarged and swollen
What management techniques are available for OA?
Educate and reassure Initial management - activity modification, rest and ice - strength training and aerobic exercise - pain relief Late stage - corticosteroid injection to help relieve pain & swelling - surgical options are available
What is adhesive capsulitis and what are its effects?
“frozen/stiff shoulder”
Limited AROM and PROM, especially ER
Thickening of the glenohumeral joint capsule leads to stiffness and dysfunction
Describe the progression of adhesive capsulitis and how long does it take to resolve?
Stage 1 (freezing phase) - complain of shoulder pain, especially at night - ROM is usually normal Stage 2 (freezing phase) - begin to develop stiffness - loss of ROM, especially IR and ER] - still painful Stage 3 (frozen phase) - profound loss of ROM - painful at extremities of movement Stage 4 (thawing phase) - persistent stiffness - minimal pain as synovitis has resolved - slow improvement in shoulder mobility
Usually a self-limiting disease that resolves in 1-3 years
Briefly describe what subacromial pain syndrome is, its symptoms, its cause, and aggravations
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
Briefly describe what rotator cuff tendinopathy is, its symptoms, its cause, and aggravations
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
What is massive inoperable rotator cuff tear, what is its mechanism, who does it affect and what are its symptoms?
Occurs in patients with RC degeneration and RC muscle failure (atrophy).
Trauma or insidious onset
Older person (over 60)
Massive loss of AROM, no loss of PROM
What would be included in a subjective history of the shoulder joint?
- Onset
- insidious/ trauma/ timescale - Pain behaviours
- location, severity, 24-hour pattern, aggs and eases - Special questions
- locking, red flags, previous dislocations - PMH and general health
- THREADS
How do glenohumeral joint related pains differ from acromioclavicular joint and sternoclavicular joint pain?
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
What special questions could you ask for the shoulder joint?
- Have you experienced problems with this area before?
- Any locking or catching?
- Persistent loss of ROM
Give some red flags for the shoulder joint
- 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
What would you look for in both the informal and formal observation?
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
How can you perform scapula wing testing, and if positive, what does this suggest?
In standing, patient flexes both arms to 90degrees and does a push up off the wall. If winging of medial border occurs = long/weak serratus anterior
What would you palpate during the objective assessment?
Temperature of area Swelling and deformity Bruising Mobility and feel of soft tissue Tenderness of bone Clavicular space
What is cervical radiculopathy and what test can be used to rule it out?
Cervical radiculopathy is when a nerve root in the cervical spine becomes inflamed or damaged, resulting in a change in neurological function.
Spurlings test
- extend neck
- lateral bend on weak side (ear to shoulder)
- downward pressure on head applied, only if symptoms are not already reproduced
What part of the body must we clear first and how?
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
What test can be performed for AC joint disorders
Scarf test/ horizontal adduction test
- arm to 90degrees flexion, maximum adduction and apply overpressure
- stress on AC joint as it becomes compressed
Name and describe 2 tests for rotator cuff related shoulder pain
- 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 - 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
Name and describe 2 tests for a supraspinous tear or tendinopathy
- Full can test
- 90degrees shoulder flexion, apply downward pressure to distal forearm - Empty can test
- 90degrees shoulder flexion, with arms IR so thumbs point down, apply downward pressure to distal forearm
If empty can = +ve and full can -ve, then not primarily a RC impingement
Name and describe 3 tests for RC tears
- ER lag sign
- 90 degrees shoulder abduction, 90degrees elbow flexion, passively ER arm to maximum, ask the patient to maintain position
- positive test = not able to maintain, impingement of infraspinatus or supraspinatus - IR lag sign
- hand of painful shoulder on lumbar region, lift hand off back passively to full IR and ask patient to maintain position.
- positive test = hand moves towards back, subscapularis tear - Drop arm test
- 90degrees are abduction, ask the patient to lower smoothly
- positive test = sudden drop or weakness during lowering, supraspinatus teae
What test can be used for anterior instability?
Apprehension test
- test integrity of GH joint
- patient in supine, 90degree elbow flexion, 90degree shoulder abduction, maximum ER
- positive test = pain or fear of dislocation
- if positive, perform relocation test
- add posteriorely directed force to the GH joint
- positive test = less apprehension
What test can be used for inferior instability?
Sulcus sign test
- patient seated with hand in lap to relax biceps
- hold arm distally to elbow and pull arm distally whilst holding the opposite shoulder
- positive test = small dip below acromion
