Shoulder Flashcards
1
Q
Percentage of the population with adhesive capsulitis
A
- 2-5.3% of the population
- 4-38% in those with diabetes or thyroid issues
2
Q
Red flags for shoulder pain
A
- diseases of digestive system
- fracture of upper end of humerus
- injury of blood vessels at the shoulder and upper arm level, including avascular necrosis
- neoplasm
- osteoporosis with pathological fracture
3
Q
Yellow flags for shoulder pain
A
- persistant somatoform pain disorder
- psychological and behavioral factors associated with disorders or diseases
4
Q
To rule in adhesive capsulitis…
A
- 40-65 y/o
- gradual onset and progressive worsening of pain and stiffness
- Glenohumeral PROM is limited in multiple directions
- ER most limited, especially when combined with ABD
- ER and IR ROM decreases as humerus is abducted from 45-90 degrees
- PROM into end ranges reproduces patient’s pain (capsular)
- Glenohumeral glides limited in all directions
5
Q
To rule out adhesive capsulitis…
A
- PROM is normal
- Radiographic evidence of glenohumeral OA
- Passive glenohumeral ER and IR ROM increases as humerus is abducted from 45-90 degrees
- familiar shoulder pain reproduced with palpation of the subscapularis
- ULTT reproduces familiar symptoms
- familiar shoulder pain reproduced with palpation of nerve entrapment sites
6
Q
Adhesive capsulitis stages
A
- early, often confused with subacromial impingement syndrome
- painful/freezing stage
- frozen stage
- thawing stage
7
Q
Stage 1
A
- early, up to 3 months
- sharp pain at end of ranges
- achy pain at rest
- sleep disturbed
- patho-anatomical…synovial reaction but no adhesions or contractures
- differential diagnosis: subacromial impingement syndrome
8
Q
Stage 2
A
- Freezing
- 3-9 months (6 months total)
- gradual loss of ROM in all directions due to pain
- aggressive synovitis
9
Q
Stage 3
A
- Frozen
- lasts 9-15 months (6 months total)
- pain and significant loss of ROM
- capsuloligamentous fibrosis results in loss of axillary fold
10
Q
Stage 4
A
- Thawing
- 15-24 months (9 months total)
- decreased pain
- motion restricted
- capsuloligamentous complex fibrosis and receding synovial involvement
11
Q
Interventions for adhesive capsulitis
A
- intra-articular injections combined with manual therapy and stretching may provide short term pain relief.
- match level of treatment with tissue irritability
12
Q
High irritability
A
- high pain levels (>7/10)
- consistent/constant pain
- high self reported disability
- pain occurs before end range
- AROM significantly less than PROM
- interventions
- -> heat and e-stim
- -> patient education on activity modification
- -> grade I and II joint mobs
- -> pain free PROM and AAROM
13
Q
Moderate irritability
A
- 4-6/10 pain
- intermittent night or resting pain
- moderate levels of disability on self reported outcome tools
- pain at end ranges of active or passive movement
- AROM is equal to PROM
- Interventions
- -> heat and e-stim
- -> patient education
- -> moderate intensity joint mobs
- -> moderate stretching
- -> progressing intensity with duration without post treatment soreness
- -> integrate gains in mobility with scapulohumeral movement. Performance of reaching activities
14
Q
Low irritability
A
- <4/10 pain
- no night or resting pain
- minimal levels of disability on self reported tools
- pain with overpressure into end range PROM
- AROM equal to PROM
- interventions
- -> patient education
- -> end range joint mobs, grade III and IV
- -> progressive duration into stretching
- -> scapulohumeral movement during higher level performance activities. Working into recreational activities/training
15
Q
Differential diagnoses for shoulder impingement/RTC syndrome
A
- adhesive capsulitis
- injury of muscle and tendon at UE level (labrum)
- injury of nerves at UE level, including suprascapular involvement
- OA of AC joint or GH joint
- cervical spine referral
- pain in thoracic spine
- sprain of AC joint or SC joint
16
Q
Glenohumeral OA symptoms
A
- pain and stiffness with activity, osteophytes, 24 hour pain behavior or stiffness in AM or after rest
17
Q
Glenohumeral instability symptoms
A
- feeling of giving out, possible dislocation history and positive special tests
18
Q
Referred pain symptoms
A
- associated neck and thoracic signs and symptoms, myofascial structures
19
Q
Adhesive capsulitis symptoms
A
- slow onset of shoulder stiffness and limited ROM
20
Q
AC joint symptoms
A
- TTP over AC joint and pain over top of shoulder
21
Q
Nerve entrapment symptoms
A
- suprascapular or long thoracic nerve palsy
22
Q
Labral tear symptoms
A
- deep and vague shoulder pain associated with clicking, popping, and catching.
23
Q
Biceps tendonopathy symptoms
A
- pain and tenderness over anterior shoulder with associated TTP over bicep tendon
24
Q
Stage I of impingement
A
- edema and hemorrhage
- mechanical irritation of tendon with overhead activity
- younger/athletic population
25
Q
Stage II of impingement
A
- fibrosis and tendonitis
- repeated episodes of mechanical irritation
- thickening or fibrosis of subacromial bursa
- age 25-40
26
Q
Stage III of impingement
A
- Bone spurs and tendon rupture
- continual mechanical compression of RTC
- RTC tears, biceps tendon lesions, bony alterations of acromion
27
Q
Secondary impingement
A
- underlying instability of GH joint
- associated dysfunction of static stabilizers (capsular ligaments, labrum), and dynamic stabilizers (neuromuscular control)
- not necessarily associated with patho-anatomical finding
28
Q
RTC impingement test cluster
A
(+) hawkins kennedy
(+) painful arc
(+) IR muscle test
-High probability (+) neer, (+) empty can along with aforementioned tests
29
Q
Instability vs laxity
A
Laxity: can be normal and asymptomatic
Instability: is symptomatic and patients have pain, apprehension, fear, parasthesia, fatigue. There is loss of centering of humeral head in glenoid
30
Q
Traumatic instability (TUBS)
A
- Traumatic
- Unidirectional
- Bankart lesion
- Surgery is required
31
Q
Atraumatic instability (AMBRII)
A
- Atraumatic
- Multidirectional
- Bilateral
- Rehab is choice
- Inferior capsular shift
- Internal closure
32
Q
Types of instability
A
- congenital
- multi directional
- primary dislocation
33
Q
Multi directional instability
A
- dislocation of GH joint
- (+) sulcus sign may be acquired
34
Q
Multi directional instability considerations
A
- capsular enlargement
- GH ligament incompetence
- increased GH volume
- excess laxity
- shape of glenoid cavity
- muscular imbalance or neuromuscular control issues
- underlying connective tissue pathology
- those with a high beighton score
35
Q
Primary dislocation
A
- dislocation and subluxation of GH joint
- age of 20’s is common as well as 60’s
- most commonly displaced anteriorly
- 95% first time dislocation trauma
- often athletes or sports related injuries
- Remainder are from MDI or congenital instability
36
Q
Primary dislocation anterior MOI
A
- Forced shoulder ER and ABD
- FOOSH
- direct force to posterior humeral head
37
Q
Possible related issues post dislocation
A
- anterior labrum detachment (Bankart lesion)
- compression fracture of humeral head (hill-sachs lesion)
- scapulothoracic motion issues
- proprioception loss
- re-occurence (70% in 2 years after first)
38
Q
Anterior instability
A
- pain with cocking phase of a throw
- shoulder in ER and horizontal ABD
39
Q
Posterior instability
A
- pain during follow through
- shoulder in IR and horizontal ADD
40
Q
Symptoms of rotator cuff tear
A
- c/o anterior/lateral shoulder pain
- compensatory shoulder shrugging with overhead motion
- gross functional disabilities
- constant achiness in the shoulder
- night pain - pain that wakes the patient during sleep
- patient age of 40 or greater
41
Q
Symptoms of anterior capsulolabral instability, anterior labral lesions, or bankart lesions
A
- c/o anterior shoulder pain
- apprehension and/or pain in positions of ABD and ER
- a history of anterior/inferior trauma
- recurrent or volitional anterior/inferior subluxation and/or dislocations
- joint clicking/clunking
- complaints of joint locking
- a history of “dead arm syndrome”
42
Q
Symptoms of posterior capsular instability or labral lesions
A
- c/o deep posterior pain
- apprehension and/or pain in positions of horizontal ADD
- apprehension or pain during activities that involve pushing (especially coupled with horizontal ADD)
- apprehension or pain during closed kinetic chain positions
- a history of posterior/inferior trauma
- recurrent or volitional posterior/inferior subluxations and/or dislocations
- complaints of joint clicking/clunking
43
Q
Symptoms of SLAP lesion
A
- C/o deep shoulder pain, clicking/clunking, complaints of joint locking
- pain with activities that require eccentric deceleration of the upper extremity (such as throwing or swinging)
- pain with muscular loading of the biceps (especially during shoulder flexion and arm supination)
44
Q
Symptoms of articular-sided internal impingement syndrome of the rotator cuff
A
- c/o very specific posterior/superior pain during shoulder ABD and ER
- possible pain during activities that require eccentric deceleration of the upper extremity (such as throwing or swinging an object)
45
Q
Symptoms of long head of bicep tendinopathy
A
- c/o anterior pain
- painful palpation to the proximal aspect of the long head of the biceps
- pain with activities that require eccentric deceleration of the upper extremity (such as throwing or swinging an object)
- pain with muscular loading of the biceps (especially during shoulder flexion and arm supination)
46
Q
Acromioclavicular joint lesions
A
- c/o superior joint pain
- pain with end-range elevation activities
- pain with horizontal adduction activities
- painful palpation to the AC joint
- a notable AC joint “Step-off” on observation
- an injurious mechanism that involves a fall on the shoulder
47
Q
Internal rotation resisted strength test
A
- if internal rotation strength is less than external rotation strength is positive for intra-articular pathology
- -> glenoid erosion or labral tears, middle GH ligament tearing, articular sided RTC partial tears, posterior labral lesions, and SLAP tears
- if internal rotation strength is greater than external rotation strength the test is positive for RTC pathology
- -> thickened or inflamed subacromial bursa, erosions on the CA ligament and undersurface of the acromion, bursal side partial or full thickness RTC tear
