Shoulder Flashcards
Name all AC joint ligaments
anterior, posterior, superior, inferior
What direction do AC ligaments provide stability?
anterior posterior direction
Name all coracoclavicular ligament portions
conoid(medially) and trapezoid(laterally)
What direction do CC ligaments provide stability?
superior inferior direction
-conoid > trapezoid
When does middle GH ligament most contribute to shoulder stability?
shoulder abducted 45* and externally rotated
Name both bands and relative positions of inferior GH ligament
anterior band (2 to 4 o clock)
-resists anterior translation when shoulder abducted 90 degrees and externally rotated
posterior band (7 to 9 o clock)
-resists posterior translation when shoulder flexed and internally rotated
What does inferior GH ligament mainly stabilize?
primarily inferior GH joint translation
Force couples at GH joint
subscapularis and infraspinatus provide dynamic stability
-compressive force in transverse plane
-infraspinatus prevents superior and anterior translation
-subscapularis involved w/ forward flexion
all rotator cuff muscles and deltoid muscles
-compression to offset force of deltoid and pec muscles
Greatest predictors for failed surgical repair of rotator cuff tear
Fat infiltration OR=9.3
Multiple tendon involvement OR=6.0
Larger tear size OR=4.3
Lower pre-op muscle strength OR=4.0
Older age OR=2.8
Nociceptive pain
arises from damage to non-neural tissues
-due to activation of nociceptors
AKA pain from other tissues that activates pain receptors
typically a localized pain in the shoulder
Nociplastic pain
arises from altered nociception
-despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease/lesion of the somatosensory system
AKA pain from nociceptors firing, although no overt link to damage or disease
Neuropathic pain
arises from a lesion or disease of the CNS or PNS
-may follow a radicular pattern
AKA pain from somewhere in the nervous system
What is Parsonage-Turner syndrome?
rare syndrome causing UE weakness, atrophy and wasting
-about 1.6 people per 100,000 each year
-risk factors include postoperative, post-trauma, post-vaccination, post-infection
essentially brachial plexus neuropathy
-acute onset radiating pain followed by weakness and numbness
usually resolves in 18-24 months
-age is a factor and long term complications/deficits exist
OSPRO-ROS for Red Flags
23 item version accurately identified 100% of responders with potential red flags
shorter 10 item version accurately identified 94%
OSPRO-ROS for Yellow Flags
17 item tool
-identifies yellow flags 85% of the time and estimates multiple psychological questionnaire scores w/o pt having to complete` each instrument
Keele STarT MSK Tool
similar to STarTBACK tool
-stratifies pts into low/medium/high risk of likelihood of persistent pain, disability, and poor treatment outcomes
MCID for NPRS for shoulder pain
2 points
-example would be manual correction to a movement and then subsequent change in concordant sign
define concordant sign
movements or positions that reproduce the pt’s priary complaint
modified painDETECT questionnaire for shoulder
reliable and sensitive to discriminate nociceptive vs neuropathic pain
score of -1 to 38
12+ suggests primarily neuropathic pain presentation
Hand Held dynamometer MDC
15% change is MDC in “make test”
Subacromial pain syndrome test cluster
-Neer Sign
-Hawkins Kennedy
-Jobe(empty can)
-painful arc
-pain/weakness w/ resisted shoulder ER
3 of 5 positive
+LR 2.93
-LR 0.30
+LR 10.56 when (hawkins, painful arc, painful ER)
-LR 0.17 when all 3 negative
Test cluster for anterior instability
-Apprehension test
-relocation
-anterior release(surprise)
Sensitivity 81%
Specificity 98%
+LR 39.7
-LR 0.19
Test cluster for posterior instability
posterior apprehension test
Sensitivity 19%
Specificity 99%
+LR 19
-LR 0.82
Test for inferior instability
hyper-abduction test
SN 67%
SP 89%
+LR 6
-LR 0.37
Test cluster for multidirectional instability (MDI)
at least 2 directions of positive tests
-anterior apprehension, posterior apprehension, hyperabduction
AND
Beighton score 5/9 or higher
Primary vs secondary adhesive capsulitis
Primary
-loss of AROM/PROM specifically ER, pain w/ end ranges of motion
-more common in women, diabetes, hypothyroidism, other autoimmune disease
-requires referral for X-ray to rule out serious pathology or differentiate early OA at GH
Secondary
-typically a result period of immobilization(surgery, injury, etc)
Adhesive capsulitis 4 stage continuum
- pre-freezing
- freezing
- frozen
- thawing
~18 months after appearance of initial symptoms
Rotator cuff tear sizes
Small < 1 cm
Medium 1-3 cm
Large 3-5 cm
Massive >5 cm
measured by greatest diameter
Shoulder dislocation data
typically anterior > posterior
-posterior caused by trauma (67%) or seizure (31%)
7x more common in young males than age matched females
most occur age 15-29 but second peak occurs in women > 70yo
Primary GH joint dislocation plan of care
immobilization in traditional sling < 1 week
-encourage weaning
restore ROM and then early RTC and scapular isometrics
expect less pain after 10-14 days
-progress ROM in safe ranges, motor control, proprioception
SINEX program > traditional care for instability at 12 weeks
SINEX program vs standard care(Rockwood program) for GH instability
Watson program vs Rockwood program
SINEX>Rockwood
Watson> Rockwood
essentially, neuromuscular control, stability, etc are superior to resistance band exercises for shoulder and scapula
Hallmark findings of GH joint OA
-increasing stiffness
-ROM loss
-pain w/ joint compression
-functional limitations
Should be suspected w/ age >60 who have adhesive capsulitis
General post-op rehab principles
early mobilization for
-arthroscopic capsular release
-subacromial decompression
-biceps tenotomy
period of immobilization for
-RTC repair
-joint arthroplasty
-shoulder stabilization
Rehab phases post-op
1 immobilization
2 early mobility (PROM and AAROM)
3 progressive strength/loading
4 individualized high demand activity
TSA vs Reverse TSA
TSA requires intact RTC
Reverse TSA for patients w/ RTC arthropathy, GH joint OA w/ irreparable RTC tear, some fractures or tumors
DASH
0 to 100%
-absence of disability towards total disability
MDC = 6.6-16.1
MCID = 8.2-11.7
MDC 10.5 and MCID 10.2 per
Adhesive Capsulitis CPG 2013
QuickDASH
0 to 100%
-absence of disability towards total disability
MDC =11.0-20.4
MCID = 8.0-15.9
**strongly correlated w/ DASH, just quicker to complete
ASES (association of shoulder & elbow surgeons)
0 to 100%
-worst pain & function towards best pain & function
Subscales
-pain 0-50
-ADL 0-50
MDC = 9.4
MCID = 6.4-21.9
MCID 6.4 per Adhesive Capsulitis CPG 2013
SPADI (shoulder pain & disability index)
0 to 100%
-absence of pain and disability toward total pain & disability
Subscales
-pain 0-50
-disability 0-50
MDC = 18.0
MCID = 10
MCID 8-13 per Adhesive Capsulitis CPG 2013
PSS (penn shoulder scale)
0 to 100%
-worst pain/satisfaction/function toward best
Subscales
-pain 0-30
-satisfaction 0-10
-function 0-60
MDC = 12.1
MCID = 11.1
PSFS (patient specific functional scale)
0 to 100%
-worst function to best
MDC = 1.0-2.5
MCID = 0.8-3.0
SANE (single assessment numeric valuation)
0 to 100%
-worst pain and function to best
MDC = 6.7-8.6
MCID = 11.8-18.0
Constant-Murley Score
0 to 100%
-total pain & disability, worst objective measure
toward absence of pain and disability, normal objective measures
combines subjective questions w/ objective measures
Subscales
Pain 0-15
ADL 0-20
ROM 0-40
Strength 0-25
MDC= 17.7
MCID = 5.5-30
WOSI (western ontario shoulder instability index)
0 = absence of disability
2100 = total disability
0% = total disability
100% = normal function
Subscales
Physical symptoms 0-1000
Sports/rec/work 0-400
Lifestyle 0-400
Emotions 0-300
MDC = 339.3
MCID = 210-220
WORC (western ontario rotator cuff index)
0 = absence of disability
2100 = total disability
0% = total disability
100% = normal function
Subscales
physical symptoms 0-600
Sports/rec 0-400
Work 0-400
Lifestyle 0-400
Emotions 0-300
MDC= 19.1 of 100
MCID = 245-300
WOOS (OA index of the shoulder)
0 = absence of disability
1900 = total disability
0% = total disability
100% = normal function
Subscales
Physical symptoms 0-600
Sports/rec/work 0-500
Lifestyle 0-500
Emotions 0-300
MDC = 19.1 of 100
MCID= 245-300
shoulder imaging signs in AP view
half moon sign
-NORMAL overlap of humeral head and scapula
-indicates NO dislocation
-loss of halfmoon sign indicates posterior dislocation as humerus sits farther away from scapula
lightbult sign
-indicative of posterior dislocation
-humerus internally rotates, resembles lightbult
posterior dislocations can cause reverse hill-sachs lesion
