Shoulder Flashcards
what is a red flag?
symptoms that may require immediate attention and supersedes physical therapy
what is a yellow flag?
confounding variables which may be cautionary warnings regarding the patient’s condition, that require further investigation and for you to proceed with caution
numerical pain rating scale (NPRS)
rate pain 0-10
higher score indicates more pain
patient specific functional scale
-rate ability to perform 1-5 functional tasks on 0-10 scale
-scores are averaged
-lower score= greater disability
global rating of change
-recall based rating of change in wellbeing on an 11 point scale
0= no change
+5= meaningful improvement
-5= meaningful deterioration
disabilities of the arm, shoulder, and hand (DASH)
-30 items (21 physical, 5 pain, 4 emotional)
-scores range from 0-100
-higher score= greater disability
quick-DASH
-11 items addressing symptoms and physical function
-scores range from 0-100
-higher score= greater disability
shoulder pain and disability index (SPADI)
-13 items (5 pain, 8 disability) rated 0-10
-scores range from 0-100
-higher score= greater disability
penn shoulder score (PSS)
-rate level of pain, satisfaction, and function on 3 subscales
-pain and satisfaction scale both 10 point numeric rating scale
-function scale is 4 point likert scale
-scores range from 0-100
-higher score = low pain, high satisfaction, high function
what are we looking for in an upper quarter screen?
-symmetry
-quality of movement
-willingness to move
-pain
-end feel
-scapulohumeral rhythm
possible low shoulder causes
-adaptive laxity of shoulder
-leg length discrepancy
-scoliosis
-hand dominance
medial border of scapula sits
5-8cm from thoracic spine
superior angle of scapula is in line with
T2
inferior angle of scapula is in line with
T7
forward head posture may cause what positions at the scapula and shoulder?
scapula abducted, elevated, and internally rotated. shoulders protracted
equally limited/painful AROM & PROM, increased tone, strong but painful resistance
muscle tightness
equally limited/painful AROM & PROM, resistance not usually impacted, may or may not be capsular pattern
joint pain
limited AROM, painful palpation, weak and maybe painful resistance
muscle or tendon tear
painful AROM, painful stretching, painful palpation, strong but painful resistance
muscle strain or tendinitis
equally limited/painful AROM & PROM, resistance not usually impacted
ligamentous tear, sprain, or adhesion
equally limited/painful AROM & PROM, resistance not usually impacted, may or may not show capsular pattern
joint capsule hypomobility
AROM worse than PROM, uncomfortable palpation, weak resistance
nerve
referral pattern for rotator cuff injuries
anterior/ lateral upper arm. seldom goes below the elbow
causes of rotator cuff pathology
compression, tensile load, traumatic tear (macro trauma), degenerative tear (micro trauma)
tendinosis
intratendon degeneration often due to repeated microtrauma. haphazard tendon but no inflammatory response
rotator cuff tendinitis/ tendinosis symptomology
dull ache in lateral upper/lower arm
reaching away is painful
overhead activities painful
subacromial impingement is caused by what motion?
superior translation of humeral head with elevation
subacromial (outlet) impingement
-abrasion of structures in subacromial space
-shape of acromion, bone spur, tendon thickening can be factors
-pain in anterior/ lateral shoulder
what soft tissues are often involved in outlet impingement?
supraspinatus (primarily), long head of bicep, subacromial bursa
posterior internal (non-outlet) impingement
-impingement of rotator cuff muscles against posterior superior glenoid labrum and humeral head
-pain in posterior shoulder or lateral upper arm
-can be caused by repeated overhead motion
-greatest risk is with repeated arm elevation with shoulder IR
special tests for impingement
hawkins-kennedy
neer
empty can
painful arc
cross-body adduction
scapular assistance
scapular repositioning
what is a partial rotator cuff tear
damage to one or more rotator cuff tendons that leads to a tear that does not go all the way through the tendon
what is a complete rotator cuff tear
damage to one or more rotator cuff tendons that leads to a full tear where tendon is separated from bone
degenerative rotator cuff tears may be secondary to
sarcopenia, postural changes, and balance changes
rotator cuff tear symptoms
- weakness always present (amount related to size of tear)
- compensation with scapular motion
- pain when sleeping
- pain in lateral upper arm
special tests for rotator cuff tears
drop arm test
external rotation lag sign
infraspinatus muscle test
hornblowers sign
IR lag sign
belly press
lift off
empty can
rotator cuff tears greater than ___ cm are considered large
2.5cm or 1 inch
combination special tests
hawkins, painful arc, infraspinatus muscle test
2 positive = impingement
3 positive = rotator cuff tear
high specificity
causes of snapping scapula
1.inflammation of bursa between scapula and thorax
2. prominence of superomedial angle of scapula
3.muscle imbalace of scapula rotators
4. rib fracture
5. benign excess growth of bone on scapula
6. sprengel’s deformity
commonly tight muscles contributing to scapular dyskinesia
pec minor, posterior shoulder capsule, levator scap, latissimus dorsi, infraspinatus, teres minor
commonly weak muscles contributing to scapular dyskinesia
lower and mid trap, serratus anterior
symptoms of shoulder posterior instability
-instability with shoulder in flexed/ abducted position
-pain
-guarding
posterior shoulder instability special test
jerk test
symptoms of shoulder inferior instability
-pain
-guarding
-carrying weighted objects uncomfortable
shoulder inferior instability special test
sulcus sign
shoulder anterior instability special tests
-apprehension test
-relocation test
complications of anterior dislocation
-neurovascular injury
-hill sachs lesion
-bankart lesion
-SLAP tear
what is a bankart lesion
tear of anterior inferior labrum. AKA inferior labral tear
what score on the beighton scale represents hypermobility
4+
AMBRI
atruamatic multidirectional bilateral for rehabilitation and possibly inferior capsular shift surgery
TUBS
traumatic unilateral bankart needing/ responding to surgery
labral tears present similarly to ____ pathology
rotator cuff or instability
SLAP tear
superior labral lesion from anterior to posterior. commonly involves long head of the bicep
presentation of labral tear
pain in anterolateral arm
aggravation with overhead activities
pain with behind the back activities
locking/ clicking/ popping/ catching
tenderness over anterior shoulder
labral tear special tests
o’brien test
biceps load 2
anterior slide
compression rotation (grind) test
speed test
yergasons
observable deformity, local tenderness, and pain with end range shoulder motion are all consistent with what injury?
SC joint
Type 1 & 2 AC joint injury treatment
immobilization period, gentle ROM, isometric exercises, progression to scapular stabilization exercises
type 3 AC joint injury treatment
surgery or conservative
immobilization period, progression to PROM, progressive shoulder strengthening, return to sport 6-12 weeks, reconstruction if limitations persist past 3 months
type 4,5,6 AC joint injury treatment
surgery
progress toward full ROM then strength progression, manual therapy, scapular stabilization, proprioception training
mechanism of traumatic AC joint injury
humerus is driven inferiorly with force. usually MVA or sport related
mechanism of degenerative AC joint injury
previous trauma or insidious onset. pain is worse in the morning after prolonged rest
AC joint injury presentation
localized pain, pain at end range shoulder AROM and PROM, possible deformity, pain with resistance (especially shoulder elevation)
AC joint special tests
AC joint palpation
cross-body adduction
AC resisted extension
paxino’s test
risk factors for frozen shoulder
diabetes (5-6x more likely)
prior history
thyroid disease
what conditions are frozen shoulder often misdiagnosed as?
impingement or rotator cuff tendinitis/tear
stage 1 of frozen shoulder
0-3 months (pre-adhesive). mild symptoms, achy at rest but sharp at end range. capsular pattern loss of ROM, strong but possibly painful
stage 2 of frozen shoulder
3-9 months (freezing stage). persistent more intense pain even at rest. multidirectional loss and pain at end range. pain referred to lateral upper arm & night pain sets in
stage 4 of frozen shoulder
15-24 months (thawing). minimal pain and gradual return in ROM. stiffness and fibrosis may remain. receding synovial involvement
stage 3 of frozen shoulder
9-14 months (frozen). painful stiffening of shoulder and significant ROM loss. pain may be lower than stage 2 but ROM still worse. poor scapulohumeral rhythm
high irritability characteristics
-pain 7+/10
-night or resting pain
-high level of disability reported on outcome measures
-pain before end ranges of active or passive movements
-AROM < PROM due to pain
moderate irritability characteristics
-pain 4-6/10
-intermittent night or resting pain
-moderate level of disability reported on outcome measures
-pain AT end range of active or passive movements
-AROM = PROM
low irritability characteristics
-pain 3/10 or less
-no night or resting pain
-minimal level of disability reported on outcome measures
-pain with over pressures into end ranges of passive movements
-AROM = PROM
Non PT interventions for frozen shoulder
-NSAIDS
-steroids
-steroid injection
-manipulation under anesthesia
-hydrodilation
-arthroscopy
-open release
selective hypomobility presentation
-possible decreased ROM
-possible increased joint translation in the opposite direction
-possible pain at end range
subacromial bursitis presentation
-similar findings as impingement
-pain develops gradually in lateral upper arm
-one or more resistive tests commonly painful
-conservative treatment
calcified bursitis presentation
-similar findings as impingement
-secondary to decreased vascularization
-produced non capsular limitation in movement
-pain develops gradually in lateral upper arm
-one or more resistive tests commonly painful
-conservative treatment
calcific tendinopathy presentation
-uncommon esp under age of 40
-reactive calcification of rotator cuff tendons
-cause unclear but could be hypovascularization, degeneration of tendon, metabolic disturbances
bicipital tendionopathy presentation
-often secondary to impingement
-in younger population may be due to repeated trauma (pitcher)
-in older could be degenerative
-tenderness of bicipital groove
-painful resisted shoulder and/ or elbow flexion
+ speeds + yergasons
subluxing biceps tendon presentation
-could lead to tendinopathy or rupture
-click may be present
-tenderness over bicipital groove
-painful resisted elbow flexion
+ speeds + yergasons
GH osteoarthritis symptoms
-anterolateral shoulder pain
-A/PROM limitations
-crepitis
-weakness
-diminished mobility
-relief with traction
AC joint osteoarthritis symptoms
-pain at AC joint
-pain with OH activities especially at end range
-painful/ limited shoulder AROM
+ ac palpation test
+ cross-body adduction
+AC resisted extension
what actions reproduce trigger point symptoms?
stretching, activating, palpation
populations at greater risk for humerus fracture
children
older adults
females
diabetes
components of proximal humeral fractures
number of fractured parts
-greater
-lesser
-surgical neck
-anatomical neck
displacement
proximal humerus fracture potential causea
low energy fall in elderly with osteoporosis
high energy fall/ FOOSH
Systems review findings of proximal humerus fracture
integument may show possible swelling and bruising. check neuro and cardio distal to fx for potential vascular/ neurologic injury
what should be avoided for a proximal humerus fracture?
-ROM (risk of displacement)
-MMT of shoulder, scap, and elbow if not healed
-joint mobility of glenohumeral joint
special test for proximal humerus fracture
olecranon-manubrium percussion test
what comorbidities may slow healing time post sx of humerus fracture?
-severe osteoporosis
-smoking
-drug and alcohol use
-diabetes
-RA
-immunocompromised
goals of PT after fracture has healed
-regain AROM/ PROM
-strengthen
-improve function
clavicle fracture examination history
low energy fall in elderly with osteoporosis
high energy fall/ FOOSH
Clavicle fracture systems review
integumentary may show swelling/ bruising. check neuro and cardio for potential vascular neurologic injury
clavicle fracture contraindications
-ROM testing
-MMT
-joint assessment of SC & AC joints
clavicle fracture healing times
6 weeks in children
8 weeks in adults
most common shoulder injuries in throwing athletes
-rotator cuff impingement
-snapping scapula
-labrum/ biceps complex
-joint capsule
what is GIRD?
glenohumeral internal rotation deficit. when athletes have so much ER and very little IR.
136 ER, 40 IR, 90 ABD average
components of swimmers shoulder
impingement: primarily due to IR
muscle overuse/ fatigue: teres minor, serratus anterior, subscap, pec major, lats
shoulder laxity: multidirectional but anterior in backstroke swimmers
sprengels deformity
pediatric deformity where scapula fails to descend limiting shoulder elevation. more common in girls
erbs palsy
traction injury of brachial plexus. common MOI is obstetric injury, falling, and tackling injury
erbs palsy common presentation
-difficulty moving the arm or painful
-trouble gripping
-numbness/ tingling
-arm in waiters tip position
treatment for erbs palsy
-children: use the limb
-strengthening
-ROM
-sensory stimulation
-splints/ brace/ tape
-surgery
axillary web syndrome
-complication of breast cancer affecting msk and lymphatic system
-typically occurs after sx
-cords of subcutaneous tissue
symptoms: pain, numbness, pulling, limited ROM
treatments for axillary web syndrome
-manual lymph drainage
-nerve mobilizations
-soft tissue mobilization
-patient education
-ROM
pancoast tumor
lung cancer that begins at apex of the lung.
symptoms: shoulder pain along c8- T2 similar to ulnar nerve injury, horner syndrome, weakness/ atrophy of hand muscles
