Musculoskeletal (Shoulder)

Question 1

Depends on the severity / classification (Type 1 - 6)

What pathophysiological mechanisms underpin ACJ related pain and the associated pain response?

Answer 1

1. Type I: An isolated sprain of the acromioclavicular (AC) ligaments.
2. Type II: A complete tear of the AC ligaments and a sprain of the coracoclavicular (CC) ligaments.
3. Type III: AC joint dislocation occurs secondary to complete disruption of the AC and CC ligaments. Deltotrapezial fascia remains intact.
4. Type IV: Posterior dislocation of the distal clavicle into the trapezius muscle.
5. Type V: Includes the same injury to the ligamentous structures as identified with a type III dislocation, with the addition of deltotrapezial fascia disruption. Often results in “tenting” or compromise of the skin covering the AC joint.
6. Type VI: An inferior dislocation of the distal clavicle can be subacromial or subcoracoid and may be associated with other potentially severe injuries, such as rib fractures and brachial plexus injuries.

Note: Type I and II Injuries are most commonly attributed the “ACJ related pain” label due to limited clinically discernable features and reduced reason for further diagnostic investigation.

PAIN
Predominantly nociceptive

Question 2

What are the predominant patient-reported dysfunctions for ACJ related pain?

Answer 2

• Pain in the top of the shoulder
• Pain with horizontal adduction ie) hugging, putting on a scarf
• Radiating pain to neck and shoulder, worse with movement
• Unable to sleep on affected side

Question 3

What dysfunctions may be found during an objective assessment for ACJRP?

Answer 3

• Depending on the severity, a step-down bone deformity can be seen (lateral end of the clavicle is raised).
• Swelling and or bruising around AC joint
• Potential restricted, painful active and passive ROM.
• High arc pain.
• Positive result for scarf test, psychometrics
• Pain provocation upon direct palpation of the AC joint in absence of provocation to surrounding areas– this is the most reproducible clinical sign (Johansen et al, 2013).

Question 4

What are the psychometric properties of the scalf test (with reference)?

Answer 4

• Sensitivity = 0.77 - 1.00
• Specificity = 0.79
• +LR = 3.67/-LR = 0.29

Powell & Huijbregts, 2013 – systematic review

Question 5

Consider findings from: Natural Hx, AROM, PROM, Strength, Pain & STs

Talk through your differential diagnoses for ACJRP, RCRPS, and Frozen Shoulder.

Answer 5

Question 6

Can you remember / visualise the Oxford Shoulder Clinic Algorythym

Answer 6

Question 7

Think generally and specific to the three stages

What pathophysiological mechanisms underpin Adhesive Capsulitis and the associated pain response?

Answer 7

• Thickening of Synovial Capsule
• Adhesions to the biceps tendon, and/or obliteration of the axillary fold secondary to adhesions
• Excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction

Stages of the pathology
1. Freezing Stage (3-9 months) = acute synovitis of GHJ
1. Frozen Stage (4-12 months) = pain does not necessarily worsen
1. Thawing Stage (12-42 months) = gradual return of shoulder mobility (12)

PAIN
Nociceptive dominant

Question 8

What are the predominant patient-reported dysfunctions for Adhesive Capsulitis?

Answer 8

Severe pain at night
Insidious shoulder stiffness

Question 9

What dysfunctions may be found during an objective assessment for Adhesive Capsulitis?

Answer 9

• Global loss of glenohumeral ROM: mainly with passive external rotation and abduction.
• In a true frozen shoulder there is almost complete loss of external rotation. This is the pathognomonic sign of a frozen shoulder.

Question 10

What modifiable and non-modifiable risk factors influence Adhesive Capsulitis?

Answer 10

Non-modifiable
* Age: Peak age is 56 but is also prevalent in men and women aged between 40 and 60 years. Frozen shoulder is rare under the age of 40.
* Sex: Occurs slightly more often in women than in men.
* Thyroid dysfunctions.

Modifiable
* Diabetes mellitus

Question 11

What modifiable and non-modifiable risk factors influence ACJRP?

Answer 11

Non-modifiable
* Trauma/injury: e.g. car crash, fall, direct impact

Modifiable
* Participation in contact sports
* Obesity (confounding)

Question 12

At 6 weeks, 12 weeks, and 9-12 months

What is the prognosis for conservatively managed ACJRP?

Answer 12

1. 6 weeks - functional motion
2. 12 weeks – normal activity
3. 9-12 months – Full recovery and return to maximum strength and function.

• Pain after nonoperative treatment is typically secondary to posttraumatic arthritis, which has been seen radiographically in 29% to 75% of individuals.
• Type I and II acromioclavicular joint disruptions impair long-term shoulder function in about half of patients 10 years after injury.
• Typically, athletes can return to sport in 2-3 weeks with caution.

Question 13

What’s the prognosis for Adhesive Capsulitis / Frozen Shoulder

Answer 13

• Wide variation in recovery ranges between 6 months and 3.5 half years.
• Can last longer than 3.5 years and may even never resolve.
• A prospective study showed that 39% had a full recovery, 54% had clinical limitation without functional disability, and 7% had functional limitation.
• Shaffer et al showed that 50% of patients with FS had some degree of pain and stiffness an average of seven years after the onset of the disease.

Question 14

Three conceptual models?

What pathophysiological mechanisms underpin RCRPS and the associated pain response?

Answer 14

RCS includes subacromial impingement syndrome (SIS) and bursitis, RC tendonopathy, partial-versus full-thickness RC tears (PTTs versus FTTs), and, chronically, can influence the development of glenohumeral degenerative disease (DJD) and rotator cuff arthropathy (RCA).
* **Tendinopathy: **pathogenesis not fully understood. Likely to be combination of 3 conceptual models involving tendon cell response, collagen disruption and inflammation.
* Impingement: Internal (Posteiror capsular tightness & internal rotation deficit) & External (encompasses etiologies of external compressive sources (i.e. the acromion) leading to subacromial bursitis and bursal-sided injuries to the RC)
* Bursitis: Inflamation of the surrounding bursal sacs.

Related to Pain
* Pain mechanism includes nociception - usually localised. Modulated by spinal, peripheral & central mechanisms.
* Non-nociceptive pathway has also been hypothesized.
* Can manifest as allodynia.
* Mirroring in opposite limb occurs occasionally
* Can exist without pain

Question 15

What are the predominant patient-reported dysfunctions for RCRPS?

Answer 15

• Pain and weakness of the shoulder, inability to lift arm above shoulder level (brushing hair, dressing, reaching), weakness, reduced ROM.
• Calcific tendinitis: severe, disabling pain occurring spontaneously in the morning.
• Mechanical block: labral pathology, frozen shoulder.
• Sensation of stiffness/instability: frozen shoulder, anterior/multidirectional instability

Question 16

What dysfunctions may be found during an objective assessment for RCRPS?

Answer 16

• Clicking/catching of the shoulder joint when moved through PROM.
• Problems with shoulder elevation and abduction in AROM.
• Painful arch of abduction, unable to reach higher than 90 degrees.
• Pain provocation on internally rotated abduction which is exacerbated against resistance.
• Anteriorflexion of the upper arm

Question 17

What modifiable and non-modifiable risk factors influence RCRPS?

Answer 17

Non-modifiable
* Age: more prevalent in the older population
* Sex: more prevalent in men
* Menopause
* Genetics
* Inflammatory and autoimmune conditions
* Diabetes
* Gout
* Excess load: Consider spike in loads, periods of deconditioning & biomechanical changes
* Past injury
* Calcific tendinopathy: Women aged 40-60yrs

**Modifiable **
* Smoking
* Repetitive overhead activity
* Excess adiposity
* Hyperlipidemia
* High cholesterol

Question 18

What is the prognosis for RCRPS?

Answer 18

• Months or 6-12 weeks with rehabilitation.
• Obesity metabolic syndromes and smoking can increase the risk and have a detrimental impact on recovery.

Question 19

What is the proccess for the shoulder objective assessment?

Clinical Physio Flashcard

Answer 19

Question 20

What are the red flags for a massive roator cuff tear?

Clinical Physio Flashcard

Answer 20

Question 21

What are the red flags for shoulder dislocation?

Clinical Physio Flashcard

Answer 21

Question 22

What are the red flags for humeral / glenoid fracture?

Clinical Physio Flashcard

Answer 22

Question 23

What are the red flags for visceral masquerades?

Clinical Physio Flashcard

Answer 23

Question 24

What are the red flags for Cancer?

Clinical Physio Flashcard

Answer 24

Question 25

What are the red flags for Avascular necrosis?

Clinical Physio Flashcard

Answer 25

Question 26

What were the key findings of Salamah et al (2020) regarding special tests for the RCPS?

Answer 26

• Shoulder “special tests” cannot identify the structure causing RCRSP symptoms.
• The so-called special tests should only be considered as pain-provocation tests. If the individual has reproduced his or her symptoms during a physiological movement, activity, or functional task, then symptoms produced during the special tests do not add additional information.
• Using special tests to inform individuals of the specific source of their symptoms, and then recommending surgical or nonsurgical intervention for that structure, is arguably not best, or even acceptable, practice.
• A comprehensive clinical interview and physical examination can be used to inform a working hypothesis to implicate RCRSP without the need for special tests.

Question 27

What is the special test cluster for RC Tears proposed by Hegedus et al, 2015 (with psychometrics)?

Answer 27

• Age: >56
• Resisted strength test: Weakness on external rotation
• Pain: Night pain present

Psychometrics
* LR(+): 9.84
* LR(-): 0.54

Question 28

What is the special test cluster for Massive RC Tears proposed by Hegedus et al, 2015 (with psychometrics)?

Answer 28

• Age: ≥ 60
• Positive painful arch test
• Positive drop arm (lag sign) test
• Positive infraspinatus test

Psychometrics
* LR(+): 28.0
* LR(-): 0.09

Question 29

What is the special test cluster for RCPS proposed by Hegedus et al, 2015 (with psychometrics)?

Answer 29

• Positive Hawkins-Kennedy
• Positive painful arc test
• Positive infraspinatus test

Psychometrics
* LR(+): 10.56
* LR(-): 0.17

Question 30

What are the key treatments for RCRPS (with references)?

Answer 30

• Education (Dube et al, 2023; Crindland et al, 2021)
• Exercise (Peters et al, 2020; Scott & Khan, 2008)
• Manual Therapy - Supplementary (Peters et al, 2020)

Question 31

What were the key findings of Dube et al (2023) regarding the treatment of RCRSP?

Answer 31

Education consisting of information on:
* Shoulder (anatomy and function)
* Basic pain science
* Advice on pain management (night and day)
* Activity modification (when to in- crease and decrease)
has proven effective at improving adherence, confidence and self-efficacy, and reduce kinesiophobia and pain catastrophising.

• Such educational provision alone has also been found to be as effective at reducing symptoms and functional limitations of individuals with RCRSP as education and exercise prescription combined

Question 32

What were the key findings of Peters et al (2020) regarding the treatment of RCRSP?

Answer 32

• Exercise therapy consisting of progressive shoulder-strengthening and stretching exercises for the RC and scapular muscles have been shown to be effective for improving pain scores, active range of motion, and overall shoulder function at short-term (6–12 weeks) and long-term follow-ups (greater than 3 months) in individuals.
• The inclusion of manual therapy alongside exercise has been shown to produce meaningful improvements in pain and function when compared to exercise alone. However, more recent research has found no additional improvements when compared to exercise alone (Paraskevopoulos et al, 2022).

Question 33

What were the key findings of Powell et al (2022) regarding the mechinisms of effect for the use of exercise in treating RCRSP?

Answer 33

Four themes identified:
1. Neuromuscular: The aim of the training program in the present study was to strengthen the musculature of the rotator cuff, which is likely to have been one of the factors that led to the improvement of pain.
2. Tissue Factors: Possible mechanisms for explaining treatment effects are improved circulation in the affected structures.
3. Neuro-endocrine-immune (DNIC): Possible mechanisms for explaining treatment effects are pain modulation by activating the gate control system in the posterior horn of the spinal cord.
4. Psychological: The mechanisms are probably several, ranging from effects on a cellular level to cognitive functions such as coping and self-efficacy.

Despite the numerous potential mechanisms, many fail to substantially improve with exercise-based treatment.

Question 34

What were the key findings of the FROST study (Rangan et al, 2020) regarding the key treatments for frozen shoulder?

Answer 34

Compared the effectiveness of three care pathways for the treatment of frozen shoulder - all of which resulted in significant improvements with none been clinically clearly superior - according to patient reported questionaires.
1. Early physiotherapy with corticosteroid injection: included information on pain management, mobilisation techniques (increasingly stretching into the stiff part of the range of movement), and a graduated home exercise programme that progressed from gentle pendular exercises to firm stretching exercises according to the stage of frozen shoulder: we’re more likely to require further treatment.
2.** Manipulation under anaesthsia** (supplemented with cortico-steroid injection) with subsequent graded physiotherapy: most cost-efffective. - provided the best value for money when considering the patients improved QoL.
3. **Arthroscopic capsular release **(supplemented with cortico-steroid injection) with subsequent graded physiotherapy: associated with greater costs and risk.

Question 35

According to Gladstone (1997) what are the three key treatment phases for ACJ related pain?

Answer 35

• Phase 1: Establish non-painful ROM, decrease pain and inflammation, and prevent muscle atrophy.
• Phase 2: Improvement in strength, endurance, and neuromuscular control through ROM
• Phase 3: Preparation for unrestricted functional participation in sport. This is where activity specific goals are worked on.