Shoulder Flashcards
what are the 2 most important questions to ask during a subjective exam
age
onset
what x-ray views are the most common
anterior posterior
lateral
how many x-ray views are always required
at least 2
when might a CT scan of the shoulder be more helpful than MRI
to look at bone (integrity of joint, ex:chronic instability to look for bone loss)
what kind of film shows osteoarthritis
plain film
what is the gold standard image for cuff tears
plain film
what kind of image can help diagnose a labral injury
MRI
T or F: you should always start with plain films for the shoulder
TT
cervical radiculopathy
dysfunction of cervical nerve root
causes scapular, shoulder, arm, and hand pain
radiculopathy
dysfunction of nerve roots tthat have already exitted tthe spinal cord LMN signs
myelopathy
compression of the spinal cord UMN findings
neurogenic TOS
compression of brachial plexus
vascular TOS
compression of the subclavian artery or vein
which type of TOS is most common
neurogenic
3 common sights of compression in TOS
1 - scalene triangle
2 - coracopectoral space
3 - costoclavicular space
what makes up the scalene triangle? what can cause TOS here
anterior and middle scalenes, first rib
scalene hypertrophy
what forms the costoclavicular space? what can cause TOS here
clavicle and 1st rib
weight on shoulders (backpack) or posture
what forms the coracopectoral space? what can cause TOS here?
pec minor and rib cage
overhead activities or anatomic abnormalities
special tests for TOS
roos, adson’s, weight, costoclavicular test
T or F: PT can manage vascular TOS
F: only neurogenic
treatment for TOS
inflammation control, postural education, ergonomic education, mobility, strength, endurance
paget-schroetter syndrome
- venous TOS with DVT
- repetitive vessel constriction with activity
- presents consistent with DVT
paget-schretter syndrome treatment
clot removal, remove compression, and stent to keep vein open
direct trauma to the SC can lead to _________ displacement while indirect trauma leads to _______ displacement
posterior
anterior
*SC joint displacements are almost always seen at ER
sternoclavicular joint injury grades (3)
type 1 = mild spring, pain with motion
type 2 = sublux with movement
type 3 = dislocation
treatment for SC joint injury
reduce inflammation, activity mod tto prevent sublux
*type 3 = go to ER
80% of clavicle fractures are ________
midshaft
T or F: nondisplaced clavicle fractures are treated non operatively
T
what 2 factors concerning clavicle fractures drive treatment
amount of shortening (2cm max)
risk of nonunion
shoulder separation vs dislocation
separation - AC joint
dislocation - glenohumeral
what are the two mechanisms for an AC joint injury
separation
degeneration
what is the most common way you injure the AC joint
falling on a tucked shoulder
coracoclavicular ligaments
conoid and trapezoid
tests for AC joint injury
cross arm adduction, active compression, paxino test, AC shear
T or F: a sling is required for AC joint separation
F: if they want to wear it they can but if they do they need to come out of it periodically to move the arm… you want to avoid stiff shoulder
rockwood classification for AC joint injury
grade 1 = sprain, AC and CC lig complex intact
grade 2 = AC complex is ruptured, CC complex intact
grade 3 = AC and CC complex are both ruptured
treatment for grade 1&2 AC joint injury
activity modification, taping, short period of immobilization, ice, NSAIDs, isometrics, pain free ROM
**grade 3 may need surgery, may not
why can you often see a bump with a grade 3 AC joint injury
because the CC ligament complex is ruptured and that is what controls superior displacement of the clavicle
AC joint arthrosis
degenerative change at the AC joint
often related to previous trauma or repetitive use (weightlifters, overhead workers)
AC joint arthrosis can progross to _________
osteolysis of joint
what image view is good to show a side by side comparison of the AC joints
Zanca
why are slings so important after AC joint surgery
to reduce stress on the graft
what is the most common complication of AC joint surgery? other complications
- loss of reduction (30%)
- infections, clavicle or coracoid fx, distal clavicle osteolysis
T or F: postop AC joint reconstruction is highly variable
T: progress based on surgeon
Your pt comes in after an injury 2 days prior where he fell off his bike. He has 6/10 shoulder pain at rest and pain with all movements. He is TTP over AC joint. What might he have? How do you treat it?
-AC joint sprain
-pt has high level of irritability so he can use a sling for comfort, LE bike, manual therapy, isometrics, and ice every 20 minutes
Your pt comes in after an injury to his shoulder 6 months ago. He has no pain at rest, only with push ups. There is scapular winging noted with push-ups. How will you treat him?
He is low irritability so focus on higher level exercises for scapular control (push up plus, punch outs, etc.)
static shoulder stabilizers
bony contact, glenohumeral ligaments, labrum
dynamic shoulder stabilizers
foce couples
-rotator cuff and deltoid (centering effect)
- traps and SA (upward rotation of scapula)
instability vs. laxity
instability = functional complaint described by pt
laxity = something PT can measure
T or F: most athletes need surgery after shoulder dislocation
F
most common shoulder dislocation
anterior (95%)
bankart tear
anterior inferior labrum
hill sachs lesion
posterior humeral head
ALPSA lesion
anterior labral avulsion
A barkart repair in on _______ while a laterjet is _________
soft tissue
bony
risk factors for recurrent shoulder dislocation
- contact sports
- structural involvement
- younger age
- male
what is a common problem after shoulder dislocations
recurrent instability
TUBS
traumatic
unidirectional
bankart
surgery
AMBRI
atraumatic
multidirectional
bilateral
rehabilitation
what test determines joint laxity
beighton criteria
*max score of 9
what nerve is commonly impaired with shoulder dislocations
axillary
special tests for shoulder instability
apprehension test, sulcus sign, relocation test, load and shift
treatment for shoulder instability
rest and protection
rotator cuff exercises
scapular stabilization
posterior capsule stretching
how long should you avoid the ABER position after shoulder dislocation or surgeyr
3 month
T or F: sling use is variable after shoulder dislocations managed operatively
T
what are posterior shoulder dislocations usually the result of
FOOSH
are most posterior locations associated with instability
no
what can result from electrocution
posterior shoulder dislocation
after a posterior dislocation, what is important to avoid during rehab
posterior loading
(planks, push ups, wrestling)
subacromial pain is also called…
shoulder impingement
neer stages of impingement
stage 1 - young, no tears, no surgery
stage 2 - 25-40, scarring, SAD
stage 3 - over 40, RC tear, RC repair
mechanical impingement of the shoulder involves…
rotator cuff, bursa, long head of biceps
patients with SA pain usually present with…
- general atraumatic shoulder pain
- painful arc of elevation
- pain down lateral arm
impingement special tests
Neer
Hawkins-Kennedy
biceps special tests
speeds, o’briens
PT treatment for SA pain
activity modification, reduce inflammation, improve GH rhythm, address ROM deficits, education
what 3 places do they do diagnostic injection for SA pain
AC joint
SA space
long head biceps tendon sheath
surgical options for SA pain
SAD (not very successful)
LH biceps tenodesis
AC joint resection
T or F: surgery has proved to be more beneficial than rehab for SA pain syndrome
F: no superior effect for surgery or injections
T or F: there is not a specific type of exercise that seems to be effective for SA pain syndrome
TT
does imaging correlate with symptoms in SA pain syndrome
no
what repetitive position causes internal impingement
ABD and ER (throwing)
posterior humeral head pinches against acromion
internal impingement is pathological when________
painful
patients with internal impingement have ______ deficit
glenohumeral internal rotation deficit (GIRD)
treatment for internal impingement
posterior capsule stretching, RC strengthening, address SICK scapula, activity modification
SICK scapula
scapular malposition
inferior medial angle protrusion (winging)
coracoid pain
scapular dyskinesia
what RC muscle most commonly tears
supraspinatus
suprasinatus OIAI
O: supraspinous fossa of scapula
I: greater tuberosity of humerus
A: abducts arm
N: suprascapular
special tests for supraspinatus
open can, drop arm, empty can
infraspinatus OIAI
O: infraspinous fossa of scapula
I: greater tuberosity of humerus
A: external rot
I: suprascpular after glenoid notch
special tests for infraspinatus
ERLS, resisted ER with arm at side
teres minor OIAI
O: lateral border of scapular
I: greater tubercle of humerus
A:ER
I: axillary
special tests for teres minor
ER in 90 ABD, hornblower sign
subscap OIAI
O: subscapular fossa of scapula
I: lesser tubercle of humerus
A:IR
N: upper and lower subscapular
what is the subscpularis nerve prone to
subcoracoid impingement because it travels under the coracoid
special tests for subscp
lift off, belly press, bear hug
how do patients with an acute rotator cuff injury often present
pain, lack of AROM with full PROM, positive drop arm
everything tends to hurt so these can be hard to evaluate
**if you can’t rule out a tear send to PCP
patients with rotator cuff tears have pain laying in what position
supine
what are indications to see ortho with RC tear
- pt desire
- full thickness tear <40 y/o
- failure to improve after 2-3mth PT
- functional loss and cont weakness
*pain is not a good indicator
most common reason for RCT diagnosis
overuse of advanced imaging
T or F: rotator cuff tear size correlated with symptoms
F
T or F: in chronic full thickness atraumatic cuff tears outcomes from PT are equal to operative interventions
T
T or F: you should always get an MRI for a suspected cuff tear
F: not for older and atraumatic… try rehab
most RC repair fail in the first ___ months. what are some reasons
2-3
- size, location, shape of tear
- quality of tissue
- intrinsic factors
- pt compliance
- aggressive rehab
- surgical technique
post-op rotator cuff repair is guided by… (2)
- repair specifics
- goals of the pt
*you want to allow for healing but also prevent stiff shoulder
cuff repair treatment progression (overall)
-first 2 weeks = sling 24/7
-supine PROM check - want 90 degrees at 2 weeks. Have pt continue to do this check every couple days educating on how to gradually increase the amount of flexion
-8 weeks = near full PROM/AAROM and some ER
-3 months = start AROM
-5 months = start loading RC
when is an MRI indicated for a cuff tear?
for younger and traumatic
*also get ortho opinion
or if they failed rehab
what motion is most restricted with adhesive capsulitis
ER (active and passive)
what 2 diseases are related to adhesive capsulitis
diabetes and thyroid disease
*can also occur after injury or surgery (greater tuberosity fracture, RC repair)
strongest recommended treatment for adhesive capsulitis
injection therapy, motion exercises and education
if a pt has surgery for adhesive capsulitis when should they start PT
ASAP… it is important to start moving the shoulder right away
PT management for adhesive capsulitis
high level irritability = rest, injection, isometrics
mobilizations, pain free AAROM, education
T or F: manual therapy shows no consistent benefit for adhesive capsulitis
TT
how long should it take to see improvement after PTT with adhesive capsulitis
6-8 weeks
if a pt has an intact RC and sufficient glenoid bone stock will they most likely have a total shoulder arthroplasity or a reverse TSA?
regular TSA
when is a reverse TSA used
massive RC tears
it eliminates the need for the centering effect of the RC and the deltoid now functions as the dominant muscle
most limiting factor of TSA
subscap re-tear
*you have to have an intact RC for good long-term outcomes with TSA
what is the most common complications after RTSA
dislocation and acromial stress injuries (you are now overloading the delts)
*cuff integrity not as critical
for RTSA, what motion should you avoid for at least 3 months
bringing hands behind back (combined extension, add, IR)
