Shoulder Flashcards
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CROSS BODY ADDUCTION TEST:
- AC sprain, pathology
- Patient: sitting
- Have the patient flex shoulder to 90°
- Examiner horizontally adducts the patient’s arm to end range
- +ve test is pain reproduction
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Which is the most common type of shoulder dislocation?
80-90% are anterior
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Types of RCT surgeries:
- Athroscopic (doens’t mean it heals faster)
- Mini-open: masive tears, partial deltoid detachment
- Open: deltoid detachment
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When does the structural inspection occur during the examination process?
after ROS, then make a decission to refer out
before the screening exam
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Labral tears usually present with:
RCT
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Humeral shaft Fx healing time and tx:
- rapid healing
- ORIF
- immobilization achieved by cast, splint, external fixation
- PROM until fx is healed
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What is AMBRI?
- Atraumatic
- Multidirectional
- Bilateral (frequently)
- Rehabilitation (often responds to)
- Inferior capsular shift (surgery)
AKA Multidirectional Shoulder Instability
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What is a Bankart lesion?
- Detachment inferior GHL complex
- 3-7 o’clock
- common with dislocations
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when does PROM (a. osteokinematic b. arthrokinematic) occur during the examimation?
after AROM
before Resistive test (MMT / MSTT)
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Visceral organs can refer pain to R and L shoulder:
-
Right shoulder: liver, stomach, pancreas, gall
bladder - Left shoulder: heart, spleen
- Both: Pancoast’s Tumor
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MOI of shoulder dislocation
AB/ER
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Why a Humeral Shaft Fx may damage the radial nerve? How would asses a radial nerve injury?
- radial nerve raps around the the mid shaft of the humerus
- sensation examination
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when does resistive test: MMT / MSTT, occur during the exam?
after PROM
before muscle lenght (if needed)
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Pain with clicking during over head motions could be…
labral tear
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Difficulty moving the arm not due to pain:
- nerve issue
- frozen shoulder (adhesive capsulitis)
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The higher the positive LR…
the better it is
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when does ROS occur during the examination?
after history
before structural inspection
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Structures that give pasive stability to the shoulder:
- bony fit
- capsule
- labrum
- ligaments:
- SGHL (0 degress)
- MGHL (45 degrees)
- IGHL (90 degress)
- CHL (0 degrees)
- CAL
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What type of joint is the AC joint?
plane joint
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Adhesive capsulitis tx:
- Modalities
- Mobilization
- Stretching
- Corticosteroid injection (after one month of PT)
- Manipulation under anesthesia (if no progress in 6 months)
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Type I slap associated with:
RCT
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Arm feels loose or slips “in or out”
possible dislocation, instability
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Moderate irritability pain scale:
4-6/10
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which RC muscles are prone to lenghten?
supraspinatus and infraspinatus
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What happens in a GRADE II AC sprain?
Surgery? Sling for how long?
Back to normal in how long?
- Complete Tear of the AC ligament and a sprain (stretching) of the CCL
- No surgery. Sling 2-4 weeks
- Rehab a minimun of 3 months
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Stages of adhesive capsulitis:
- Pre-adhesive stage: Mild synovitis patients present with mild end-range pain
- Freezing stage: Thickened synovitis acute discomfort and very painful end range movement
-
Frozen stage: Less synovitis and mature adhesions significant
stiffness with less pain (established contractures) - Thawing phase: Capsular restrictions without synovitis painless stiffness motion slowly improves
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Treatment of a prox humerus fx that opend reduced
- Some evidence that ‘immediate’ PT compared to 3 weeks immobilization (then PT) had reduced pain and better function for non-displaced fractures
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Which ligament s give the greatest passive stability to the shoulder at rest?
- SGHL
- CHL
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How is atraumatic multidirectional bilateral instability of the shoulder treated?
- Rahabilitation initially (3months)
- Inferior capsular shift repair (incision of the capsule)
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Adhesive capsulitis:
Limitations
Demographics
Other facts?
- Limitation in ext rotation the most
- Insidious onset
- Usually between 40-65 years old with an incidence greater in females
- There is between 5-35% chance it happens on the other side
- Increases to 10-40% in patients with diabetes or thyroid dysfunction
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What is the position of the pt for palpattion of infasp/teresminor?
prone on elbows, shifting their weight to the side being palpated
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most common fxs?
humerus and clavicle
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What is the goal of adhesive capsulitis PT tx?
-
GOAL: treat based on irritability
- LESS is MORE
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True or false:
Adhesive capsulitis increases to 10-40% in patients with diabetes or thyroid dysfunction
true
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Pt c/o R shoulder pain that does not change with rest. Activities/movements do not change symptoms
referred pain from liver, stomach, pancreas, gall
bladder
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Post operative Massive > 5cm RCT guideline:
- Sling: 8 weeks
- Full PROM: 12 weeks
- Isotonics: 12 weeks
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AC sprain examination test?
- AC compression
- Cross body ADD
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When are special tests performed in the examination process?
after muscle lenght if needed
before palpation
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two capsular labral pathologies:
- SLAP: 10-2 biceps involved, avoid biceps contractions
- Bankart: 3-7 (R) or 5-9 (L)
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Is the biceps tendon attached to the superior labrum?
yes
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50 y/o overweigh man, smoker, c/o billateral shoulder pain that does not change with rest. Activities does not change the symptoms:
Pancoast’s Tumor, referred pain
A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers.
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scapular winging (internal rot)?
tiping?
- SA weakness (long thoracic n damage)
- Short pec minor
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Rule in RCT:
- Supraspinatus weakness
- Weakness in ER
- Positive impingement signs
- Nigh pain
- Over 60 y/o?
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Most common clavicle fx?
Mechanism of fx?
middle 1/3rd ~ 80%
fall onto or a direct blow to the shoulder, giving an axial compressive force on the clavicle
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Which ligament gives the best pasive stability at o degrees of shoulder abb?
SGHL and CHL
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Which structures give active stability to the shoulder?
- RC muscles
- Scapulothorathic muscles:
- SA
- Deltoid
- Triceps
- Teres major
- Rhomboids
- Levator scapulae
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The lower the negative LR…
the better it is
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Shoulder muscles prone to shortness:
- Levator scapulae
- Pectoralis major and minor
- Suboccipitals
- Sternocleidomastoid
- Upper trapezius
- Scalenes
- Teres major and minor
- Subscapularis
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Which 4 signs have a great positive likehood ratio for dectecting RCT?
(+LR 28)
- Age greater than 60
- ER weakness
- Positive drop arm
- Night pain
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How does proximal humerus fx usually occurs?
trauma, FOOSH
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Which ligament gives the best pasive stability at 45 degrees of shoulder abb?
MGHL
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What is the next adhesive capsulitis tx if after 6 months of conservative mgmt (PT) there is no improvement?
manipulation under anesthesia
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Weakness and atrophy in supraspinatus and infraspinatus may be due to what?
suprascapular nerve entrapment
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which is the most common arthritic condition of the shoulder?
GHJ OSTEOARTHRITIS
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What is the chance of Hill-Sachs lesion in an anterior dislocation?
recurrence?
- 35% of dislocations
- 80% of recurrent dislocations
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What MUST the therapist check in a shoulder dislocation (can become a complication)?
- Nerve integrity, Axillary nerve
- vascular integrity, check radial pulse
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How is an intrarticular fx of the scapula treated?
ORIF
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Think instability/impingement for
younger patients especially overhead athletes
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Point scale to rule in RCT:
- 0-1 = 42%
- 2-3 = 68%
- 4-5 = 91%
- Age > 65 (2 points)
- ER weaknes (2 points)
- Night pain (1 point)
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Biceps load test:
- Labral tear (Sp: 90%)
- Examiner puts the shoulder in 120°shoulder AB and 90° elbow flexion
- Move the patient’s shoulder to end range ER
- Examiner should now resist elbow flexion
- +ve test is pain reproduction
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a positive LR of 1 to 2 and
negative LR of 0.5 - 1.0
not good
A small and rarely important shift in probability
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Objective examination includes:
- Structural inspection
- Screening exam (if there are radicular symptoms)
- Movement Analysis
- AROM
- PROM:
- Joint mobility assessment: GHJ, STJ, SCJ, ACJ
- Resistive test:
- MMT / MSTT
- Muscle lenght if needed
- palpation
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What is the the “QuickDASH”
- A functional outcome measure
- The higher the percentage the higher the disability
- 0-100%
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What nerve can get injured in prox fractures of the humerus?
axillary
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After one month of conservative mgmt (PT) if there is no improvement in adhesive capsulitis…
1 injection of corticosterois is indicated
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How are 85% of prox humerus fx treated?
The other 15?
- closed means: sling + early motion
- Surgery: pins, traction, ORIF, joint replacement
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What is likehood ratio?
combine sensitivity and specificity
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Complications in shoulder dislocation:
- axillary artery and nerve damage
- may be an associated fx to the glenoid (ORIF)
- stiffness: loss of AB/ER
- Hill- Sacks lesion
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MOI of AC sprains?
- Direct trauma
- FOOSH
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Structures through subacromial space:
- Supraspinatus
- Subacromial bursa
- LH Biceps
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A positive Biceps Load II test means that:
(in terms of 90% specificity)
- 90% sure they have a labral tear
- 10% chance to get a false positive
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direction of joint mobilization to increase external rotation?
anterior
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volleyball female player shows difficulty with external rotation. The MRI shows a cyst underneath the spine lat scapula:
may be spinoglenoid notch impigment
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Think RCT for older individuals presenting with
night pain
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Which ligament gives the best pasive stability at 90 degrees of shoulder abb?
IGHL
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Post operative Small RCT guidelines:
- Sling 1-2 weeks
- Full PROM: 6-8 weeks
- Isotonics 8 weeks
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Screening out RCT:
- No night pain (Sn 87.7)
- No arc of pain (Sn 97.2)
- No impingement signs (Sn 97.2)
- No weakness
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True or false:
Anterior shoulder dislocations always causes Bankart lesions
false
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Post operative Med-large 2-5cm RCT guideline:
- Sling: 4-6 weeks
- Full PROM: 8-10 weeks
- Isotonics: 10 weeks
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which RC muscles are prone to shortness?
subscapularis and teres minor
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Pt c/o L shoulder pain that does not change with rest. Activities/movements do not change symptoms
referred visceral pain from heart or spleen
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Classification of irritability:
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when does movement analysis occur during the examination test?
after screeening exam
before AROM
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What happens in a GRADE I AC sprain?
Sling for how long?
Back to normal in how long?
- a simple stretching of the AC ligament
- sling 1-2 weeks
- 5-6 wks back to full competition
- (ACJ sprain, direct trauma or FOOSH)
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when does the MMT test occur during the exam?
- after PROM
- before muscle lenght
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What happens in a GRADE III AC sprain?
Surgery? Sling for how long?
Back to normal in how long?
- AC and CC ligaments completetly tear
- No surgery. Sling at least 1 month (4-6 wks)
- Rehab 6 months before back to normal
- Sometimes surgery required
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What is a Hill Sachs lesion?
- Indentantion fx of the posterior humeral head
- casued by anterior dislocation
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Sulcus sign:
- Multidirectional instability
- Grasps elbow and pulls down causing an inferior distraction force
- Examiner notes in cm distance between inferior acromion and superior humeral head
- +ve test is excessive movement
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which are the 1st three steps of the examination process?
- Review of pt reported materials: intake form, imaging
- Observation
- History
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How would you differenciate a RCT from Pancoast’s tumor in older individuals presenting with night pain?
In pancoast’s tumor activities/movements do not change symptoms
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Think labral injuries for…
repetitive overhead activities or trauma
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Pt complains of pain ranges from posterior joint line to the insertion of the deltoid, RC muscle are intact, pain gets worse at night, loss of motion which has an bony end-feel
GHJ Osteorarhritis
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What is FOOSH?
Fall on Outstretched Hand
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Labral tears MOA:
traumatic or repetitive stress:
- FOOSH
- Repetitive: high eccentric activity of the biceps muscle during deceleration phase of throwing (peel-back mechanism)
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How is a traumatic unidirectional dislocation that includes a Bankart lesion treated?
surgery
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What is suprascapular nerve entrapment?
- Impigment of the suprascapular nerve in the suprascapular notch
- Weakness in supraspinatus and infraspinatus
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Who may be prone to posterior dislocation:
- extremelly rare
- MOI: ad/ir
- swimmers when they hit the wall to turn
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What is TUBS?
Shoulder instability
- Traumatic
- Unidirectional
- Bankart lesion (3-7 on the R shoulder 5-9 on the L)
- Surgery
All bankart lesions are treated with surgery
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When does AROM occurs during the examination?
after movement analysis
before PROM
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3 questions for differential diagnosis of the shoulder:
- Are the patient’s symptoms reflective of a
* *visceral disorder**? - From where is the patient’s pain arising?
- What has gone wrong with this person as a whole to cause pain?
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Type III/IV SLAP associated with:
traumatic instabilities
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direction of joint mobilization to increase abb?
inferior
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Scapulohumeral rhythm:
- GHJ 120
- STJ 60:
- SCJ 30
- ACJ 30
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- Elevated cytokine levels which cause inflammation.
- Inflammation eventually causes scarring of the rotator cuff interval, superior GH ligament and coracohumeral ligament.
- This leads to a limitation in all motion but mostly ER of the GHJ (capsular pattern)
adhesive capsulitis
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short pect minor and lower trapezius weakness may create what movement of the scapula?
anterior tipping of the scapula
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Which 3 shoulder special tests, when performed together, have a great positive likehood ratio for dectecting subacromial impigment?
- Positive Hawkins Kennedy
- Positive Painful Arc
- Infraspinatus test
- +LR 10.54
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the higher the value, the better the chance to rule in the condition or pathology
Specificity
SpIN
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Spinoglenoid notch impigment:
- difficul to diagnose
- may be confused with RCT
- supraclavicular nerve has already innervated the supraspinatus, therefore only the infraspinatues is affected (ext rota)
- volleyball players
- mostly female
- there may be a cysts
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Shoulder muscles prone to lengthen:
- Middle and lower trapezius
- Serratus anterior
- Longus colli and capitis
- Supraspinatus
- Infraspinatus
- Rhomboids
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In which type of labral tear should you avoid biceps contractions?
SLAP
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Overhead activities change symptoms may be…
- impigment
- RCT
- Labral tear
- Multidirectional instability
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Arm feels heavy after activities:
- vascular problem: arterial insuficiency
- aneurysm in axillary artery
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Treatment of GRADE IV, V VI AC sprain?
(No need to know these)
- Surgical intervention
- Reconstruction
- 6 months and over
- Very rare
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a positive LR of > 10
and negative LR of less than 0.1
Generates large and often important shifts in probability
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Think frozen shoulder for…
insidious onset, middle age females
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O’Brien test:
- Labral tear primarily
- Could be a sign of AC pathology if pain is the AC area. If so:
- AC compression test
- Cross-Body Addcution test
- Patient: sitting
- Shoulder flexed to 90 and 10°of horizontal adduction
- IR the shoulder apply resistance (auch, pain)
- ER the shoulder apply resistance (no pain, or less pain)
- +ve test is pain/clicking with the shoulder in IR
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Types of SLAP lesions:
which types have biceps tear?
- Type I: fraying of the superior labrum. May be treated conservatively
- Type II: superior labrum frayed, torn, and detachment of the biceps anchor
- Type III: bucket handle tear of superior labrum.
- Type IV: bucket tear of the superior labrum with extension into the biceps tendon. Part of the biceps anchor still intact
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Apprehension/Relocation test:
- Anterior instability
- Patient: supine shoulder in 90° of AB
- Apply maximum passive ER of the shoulder
- +ve test is the patient showing signs of apprehension (guarding, scary, may or may not be pain)
- Relocation part: apply post force on the humeral head to provide stability, external rotation
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Subject that have pain closer to end range of shoulder motion you should consider which joint as a pontential implicator?
Acromioclavicular joint
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Crank test:
- Labral tear
- Pt supine: shoulder in 160 degrees AB
- Apply a compression force to the humerus and rotate the humerus repeatedly into IR/ER
- +ve test is pain and/or clicking
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IMPINGEMENT/RC SPECIAL TESTS
- Neer Impingement Test
- Hawkins Kennedy
- ER Lag Sign
- IR Lag Sign
- Drop Arm
- Full Can
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SLAP stands for
Superior Labral tear Anterior to Posterior
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Yerganson test:
(Sp: 86%, Sn: 26%)
- biceps tendonitis
- A negative result: 74% chance you got a false negative (“useless” Dr. M)
- Flex the elbow to 90° and the forearm pronated with the arm at the side
- The examiner should resist ER and supination
- +ve test is pain reproduction
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Speed’s Test:
(Sp: 66%, Sn: 32%)
- Primarily biceps tendonitis
- Could be used for labral test
- Palapate bicepts tendon (may feel creep during the test)
- Resists shoulder flexion from 0-60 degrees
- +ve test is pain reproduced in the bicipital groove
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Shoulder dislocation tx?
Reduction: traction or traction with ER
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what is the chance of recurrence after a shoulder dislocation?
60% specially before 18 birthday
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the higher the value, the better the chance to rule out the condition or pathology
Sensitivity
SnOUT
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High irritability pain scale:
> 7/10
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Pain that occurs between 70 and 110 degrees of abduction is deemed a painful arc, and may indicate…
rotator cuff impingement, or tearing, or subacromial bursitis
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Internal (Posterior) Impingement:
special tests?
- Overhead athletes
- AB/ER (cocking phase)
- Anterior instability
-
Internal Impingement Test: Sn: 88% -LR 0.13, Sp: 96% +LR 8.2
- pt stands 90°shld AB 80°ER
- Examiner resists IR then ER
- +ve test > weakness with IR
-
Jobe Relocation Test:
- Posterior pain found upon overpressure to end range external rotation in the 90/90 position that is relieved with an posterior force would indicate posterior internal impingement.
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The pain occurs due to compression of the supraspinatus and infraspinatus tendons by the posteriorly rotated greater tuberosity of the humeral head against the posterior/superior portions of the glenoid:
Internal (Posterior) Impingement
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Pathologic contact between the margin of the posterior glenoid and the posterior tendons of the rotator cuff thatface the articular surface of the glenohumeral joint is known as
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The chronic repeated compression or impingement can cause fraying of the undersurface of the supraspinatus tendon as well as some fraying of the superior labrum which can lead to …
superior labrum anterior to posterior (SLAP) lesions
