Ortho: Shoulder

Question 1

types of injury: strain vs. sprain

Answer 1

strain: contractile tissue only (muscle/ tendon) sprain: noncontractile- joints, ligaments and capsules; usually associated with trauma. The degree to which the noncontractile structure is sprained is what determines the instability of the joint

Question 2

the shoulder

Answer 2

allows mobility but sacrifices stability- shoulder pain 3rd most common complaint.

Question 3

common problems with the shoulder

Answer 3

arthritis in any of the contributing joints (SC, AC, ST, GH, SubA), tendinitis, rotator cuff tear, instability, bursitis, calcific tendonitis, strain

Question 4

shoulder pain can be difficult to dx d/t ?

Answer 4

both intrinsic and referred pain patterns from neck, heart, organs or arm

Question 5

shoulder motions

Answer 5

Flexion and extension
 Abduction and adduction
 External and internal rotation
 Horizontal abduction and adduction

Question 6

age and common shoulder problems

Answer 6

youth- strain of muscle or traumatic- fractures and dislocations. Overuse in play/ sport. There is usually a precipitating event.

middle age- tendonitis/bursitis postural or overuse

elderly- NOT TRAUMATIC rotator cuff tear and adhesive capsulitis. Arthritis.

Question 7

sequence of exam

Answer 7

history/ interview

observe- color, asymmetry, deformity, swelling, general distress, atrophy, rupture

palpation/ inspection- temp., sensitive areas. AC joint, SC joint, biceps tendon and c spine are usually reliable. At the acromiom border- think RC and bursae.

ROM- passive and active

MMT and special tests- designed to stress suspected structures

DTR’s

Pulses

Question 8

bicep rupture

Answer 8

Popeye’s sign

Question 9

impingement syndrome

Answer 9

term currently used for the conditions of subacromial bursitis, rotator cuff tendinitis, supraspinatus tendinitis, and painful arc syndrome.

Question 10

rotator cuff

Answer 10

the tendons of the SITS group: supraspinatus, infraspinatus, teres minor, subscapularis

Question 11

RC tendonitis and impingement symptoms

Answer 11

Pain with certain motions- especially overhead, rotatory, and abduction (driving, doing hair)
Pain at night- trouble sleeping- “noc ischemia” phenomenon- teach them elevation with pillow
Can have traumatic or overuse history. Can be insidious.
Deltoid area pain is common area of referred pain

Question 12

Tests for RC Tendinits/ Impingement

Answer 12

Painful arc – between 65-120 is painful.
+ Apley Scratch- opp shoulder blade, opp inf angle scap.- doing this reproduces the pain
+ Neer- passive flexion of the shoulder with the scap stabilized and FA in pronation
+ Hawkins- passively flex the shoulder to 90, bend elbow, internally rotate
Empty can- hold “soda can” out, then turn it over to dump out the soda.

Question 13

Apley scratch

Answer 13

This first step of the Apley Grind is also called the cross arm test. It compresses the AC joint and pain in this area during the maneuver is positive for AC arthritis.

Question 14

painful arc

Answer 14

Question 15

Neer test

Answer 15

passive flxn of the shoulder with the scap stabilized and FA in pronation

Question 16

Hawkins test

Answer 16

passively flex the shoulder to 90, bend elbow, internally rotate

Question 17

RC tear

Answer 17

Age or Trauma; history of impingement
Drop Arm Test- passively lift the arm, ask to hold
Belly press- test for subscapularis tear
Lift off test behind the back test- test for subscap tear
Touchdown sign

Question 18

belly press sign

Answer 18

can’t press into their own belly. If large abdomen, try Lift Off test.

Question 19

Supraspinatus and Infraspinatus Atrophy

Answer 19

Question 20

Bursitis

Answer 20

Usually due to overuse
Can be sudden
Pain at tip of acromion into deltoid area
Difficult to discriminate between bursitis and tendinitis
Painful overhead motion
Painful to sleep on it

Question 21

Subacromial Bursa

Answer 21

Question 22

Bicipital Tendinitis

Answer 22

Pain with use
Throwing athletes- arm swing athletes
Pain more anteriorly
Positive Speeds
Positive Yergason
Possible painful arc and noc ischemia
Usually can reproduce pain when palpating the bicipital groove

Question 23

Bicipital tendinitis- Yeargason and Speeds test

Answer 23

Question 24

management of tears

Answer 24

If the patient is a surgical candidate- MRI. If not, conservative management
Usually manage pain with NSAIDS, PT. Can do PT for small tears. Large tears repaired.
If suspect tear- ortho consult. Want timely repairs before atrophy sets in for patients who would have good surgical outcomes.
Constitutional or systemic symptoms accompanying joint complaints: CBC and diff; ESR, serology for rheumatic diseases

Question 25

Management of Tendinitis/Bursitis

Answer 25

Xray if suspect calcification or SA spur
MRI? – not early on if atraumatic hx
Rest
NSAIDS 7-21 day course; Pain relievers
Ice or heat
Therapy
Positioning and activity education
Cort injections- Misplacement is problem- tendon rupture and necrosis. Ortho consult.

Question 26

Instability

Answer 26

Usually anterior inferior capsule- will report “popping in and out” or disclocation- refer.

Do apprehension test.

Question 27

Instability- Inferior

Answer 27

Sulcus sign
Instability is usually mgd by conservative PT and ortho.
Degree of pain varies- protect with sling if recent sublux/dislocations and refer.

Question 28

Review

Answer 28

Bursitis- Inflammation of bursa
Impingement syndrome/ RC tendinitis-
Irritation of structures above shoulder joint/ under acromion
Due to repeated compression between greater tuberosity and acromion process. Can lead to RC degeneration and tears
Bicipital tendinitis-
Inflammation of the tendon of the biceps brachii
Instability- laxity in the capsule or labral deficiency
Rotator cuff tear- the dynamic stabilizers are disrupted
Arthritis- point tender if AC/SC. Grinding. Age. Postive Cross Arm*- will see in the first step of the Apley Scratch test.