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Year 2- MSK > Shoulder and Elbow > Flashcards

Shoulder and Elbow Flashcards

1
Q

Red flags: Osteosarcoma (bone cancer)

A
  • Bone pain
  • Constant pain or more severity at night
  • Swelling/mass/deformity
  • Stiffness in the joint
  • Fatigue
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2
Q

Red flag: Acute rotator cuff tear

A
  • Usually following trauma
  • Pain and weakness
  • Sudden loss of ability to raise arm
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3
Q

Red flag: Polymyalgia Rhumatica (an inflammatory disorder)

A
  • Pain and stiffness in neck/shoulder/PGP
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4
Q

Red flag: Giant cell arteritis (inflammation of blood vessels in the brain)

A
  • Tenderness on scalp
  • Headaches
  • Painful jaw
  • Previous history
  • 20% of PMR develop GCA
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5
Q

Red flag: AVN of humeral head

A
  • Pain which increases overtime
  • Stiffness
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6
Q

Red flag: DVT in upper limb

A
  • Swelling
  • Pain
  • Visible collateral veins at shoulder girdle
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7
Q

Red flag: Loosening/Infection of shoulder arthoplasty

A
  • Red, hot swollen joint/wound
  • Feeling generally unwell
  • Signs of sepsis
  • Fatigue
  • New onset shoulder pain
  • Feeling of instability/giving way/dislocation
  • History of shoulder replacement
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8
Q

Glenohumeral joint instability: pathophysiology and risk factors

A

Abnormal movement of the humeral head in the gleniod fossa.
This can be anterior, posterior or multidirectional dislocation.
Can be traumatic or atraumatic
Can result in subluxation or dislocation
Stanmore classification (Jaggi and lambert 2010)
Polar 1- evidence of trauma
Polar 2- atraumatic structural instability
Polar 3- Muscle patterning- no structural deformity just abnormal coordination
Risk factors:
- Age
- Hypermobility
- Male gender
- Participation in collision sports
- Occupations involving upper limb motion above chest height

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9
Q

Signs and symptoms of instability

A
  • Clicking
  • Pain
  • Subacromial or internal impingement signs
  • Increased joint accessory motion

Anterior: increased translation anteriorly
Posterior: increased translation posteriorly
Multidirectional: increased translation in combination of directions

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10
Q

Frozen shoulder: pathophysiology and risk factors

A

Inflammation of the joint capsule.
The capsule becomes scarred and tightens therefore increasing stiffness and pain in the shoulder
Stage 1- freezing stage (painful) 2-9
- Stage 2- frozen (pain subsides, progressive loss of ROM) 4-12
- Stage 3- thawing (gradual improvement of ROM) 12 +
Risk factors:
- Female
- Over age of 40
- Prolonged immobilization
- After trauma
- Diabetes

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11
Q

Signs and symptoms of frozen shoulder

A
  • Progressive restriction to both activr and passive movement
  • Don’t tend to have crepitus (more OA of GHJ)
  • Movement restriction in capsular pattern: external rot then flexion then internal rot
  • Gradual onset
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12
Q

Management of instability

A

If traumatic: require ortho review

After relocation or atraumatic:
- Education on condition, symptom management and self management
- Direct to GP
- Physio for mobility, shoulder strengthening and proprioception

Consider referral to ortho if:
- No improvements with physio
- Recurrent dislocations
- Impacting on the person

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13
Q

Management of frozen shoulder

A
  • Education and reassurance than it can take months to years to resolve
  • Advise to modify activities
  • Direct to GP for pain meds
  • Explain that i will be painful, can affect sleep and stiffness may worsen

If symptoms don’t resolve:
- Physio: stretching, manual therapy, acupunture
- Corticosteriod injection
- Surgical management for capsular release

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14
Q

Research for frozen shoulder

A

The following interventions are suitable for primary care:
NSAIDs
Injection
Home exercise programmes- pain relieving for stage 1 and mobilisations for stage 2
Supervised manual therapy

Vivek Pandey

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15
Q

Glenohumeral and Acromioclavicular OA: pathophysiology and risk factors

A

Degenerative joint disease or inflammation of a bony joint
When cartilage or other tissues about a joint have been broken down

Risk factors:
- Age
- Obesity
- Glenohumeral instability
- Lifting heavy objects/weights (occupation)
- Chronic alcholism
- Overhead sports

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16
Q

Signs and symptoms of GHJ and ACJ OA

A
  • Pin point pain
  • Aggr by activities
  • Reduced ROM
  • Crepitus
  • Difficulty in ADLs: lifting arm
  • Progression of symptoms overtime
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17
Q

ACJ pathologies: Irritation or acute injuries

A

Account for up to 40% of all shoulder injuries
Involves overstretching or tearing of AC or Coracoclavicular ligaments resulting in subluxation and dislocation

Most common mechanisms:
Falling onto an outstretched hand
Direct impact of superior shoulder
During contact sports

Grade 1: minor tear of AC ligaments
Grade 2: vertical subluxation rupture of AC ligaments and stretching of coracoclavicular ligaments
Grade 3: Subluxation with complete rupture of AC and coracoclavicular ligaments

18
Q

Signs and symptoms of ACJ injuries

A
  • Pain and tenderness over ACJ
  • Sometimes radiation into neck
  • Aggr factors: overhead activities, reaching across body
  • Painful lying on affected side
  • Noticeable step
  • Pain worse with movement
  • Positive scarf and cross arm tests
19
Q

Management of GHJ and ACJ OA

A
  • Education: symptom management
  • Advise continuation of normal activitiees within pain limits
  • Refer to GP for pain meds and NSAIDs
  • Advise about weight loss

If not improvement:
- Physio: mobility and strengthening
- Corticosteroid injection
- Surgical option

20
Q

Management of ACJ injuries

A
  • Education on management
  • Advise rest and consider a sling for 5-7 days
  • Refer to GP
  • Start mobilisation and strengthening as symptoms start to settle
  • Avoid heavy contact for 8-12 weeks.
  • Return to normal activities

If no improvement:
- Physio
- grade 3 or higher dislocations: surgery

21
Q

Research for ACJ injuries

A

Management of acute and chroni ACJ injuries is not clarified in current literature

Aim for low grade injuries to be treated conservatively

22
Q

Biceps brachii tendinopathy: pathophysiology and risk factors

A

Caused by repetitive micro trauma to the tendon which causes micro tears
Leading to degeneration of the tendon and disorganisation to collagen
Cook and Purdam 2009 came up with the tendinopathy continuum which involved reactive tendinopathy, tendon disrepair and degenerative tendinopathy

Risks:
- Sporting activities- repetitive motions
- Affects young and middle aged more
- Degenerative changes can affect elderly

23
Q

Signs and symptoms of Biceps Tendinopathy

A
  • Throbbing, aching pain
  • Aggr factors: lifting, pulling, pushing
  • Ease: rest unless irritable
  • Usually present gradually
  • Overuse overhead activities
  • Tenderness in palpation of biceps tendon
24
Q

Biceps tendon rupture/tear of the Proximal (long-head): pathophysiology and risk factors

A

Rupture or tear of the long head of biceps tendon which attaches on top of the glenoid fossa
(do not tend to have a specific mechanism of injury unlike distal ruptures)

Risk factors:
- Age - predominately 40-60 or young people following a trauma e.g falling on an outstretched hand
- Previous shoulder problems
- Smoking
- Rheumatoid arthritis
- Corticosteriod use

25
Q

Signs and symptoms of Proximal Biceps rupture or tear

A
  • Sudden and painful popping or snapping
  • ‘popeye’ appearance
  • Pain limited weakness
  • AROM and PROm usually available but restricted by pain
  • Positive speeds, yergasons
26
Q

Biceps tendon rupture/tear of the Distal tendon: pathophysiology and risk factors

A

Tear or rupture of the biceps tendon which attaches to the bicipital tuberosity of radius

Risk factors and causes:
- Uncommon, 3% of all tendon injuries
- Common in middle-aged males
- Heavy manual jobs or sporting activities
- Excessive force being transferred through the biceps from an extended elbow position into the flexed one

27
Q

Signs and symptoms of distal biceps rupture

A
  • Trauma
  • Painful swollen elbow
  • Sudden popping sound
  • Elbow flexion and supination usually weak
  • AROM and PROM usually restricted because of pain
  • Positive hook test for complete
  • Retracted muscle in upper arm
28
Q

Management of biceps tears/ruptures and tendinopathy

A
  • Education on biceps related condition, symptom management and self management strategies
  • Advise of heat/ice application for pain
  • Advise on rest from aggr factors
  • Direct to GP

If no improvement after 6/52:
- Physio for stretching, strengthening for elbow and shoulder
- Corticosteroid injections NOT for distal rupture
- Surgeries arent use fro proximal ruptures
- Surgery for recurrent tendinopathy

29
Q

Research for proximal rupture

A

Management usually begins with:
- Non-steriodal anti-inflammatory drugs
- Physical activity: lacks analysis of outcomes]
- Injections: short term use only

30
Q

Research for distal rupture

A

Surgical intervention better than non-surgical intervention

Marco Cuzzolin

31
Q

Rotator cuff related pain: pathophysiology and risk factors

A

Its an umbrella term for different shoulder conditions:
- Subacromial pain syndrome (bursitis)
- Rotator cuff tendinopathy
Extrinsic compression= pinching of rotator cuff tendons on acromion resulting in microtrauma to cuff tendons
Intrinsic compression= degeneration leading to instability , reduction in subacromial space and increasing suseptibility of compressive factors
- Symptomatic partial and full thickness rotator cuff tears

Typically affects ages 35-75
Age- degeneration or trauma
Gender

32
Q

Signs and symptoms of Rotator cuff related pain

A
  • Pain is sharp, shooting or stabbing
  • Can have some non-dermatomal pins and needles or numbness
  • Aggr factors: lifting arm, overload activities, overhead, reaching behind back
  • Positive drop arm test
  • Severe pain and weakness with tears
  • AROM and PROM are painful
  • PROM usually full, AROM restricted in flexion and abduction
  • Positive Hawkins, Empty can
33
Q

Management of RCRSP

A
  • Education on condition, symptom and self management
  • Advise to rest during acute stage with gradual increase in activity
  • Activity modification
  • Direct to GP

If symptoms don’t improve:
- Physio: postural correction, motor control retraining, stretching, rotator cuff and scapular muscle and manual therapy (6-12 weeks)
- Subacromial corticosteriod injection
- 12/52 weeks no improvement= surgery

Exercise based approach for rotator cuff related shoulder pain like impingement, tendinopathy and partial or full tears

Manual therapy effectiveness requires further research
Jeremy Lewis

34
Q

Tennis elbow: pathophysiology and risk factors

A

Overuse injury cause by overload at the origin of the common extensor tendon
- Leading to tendinosis and inflammation of associated tendons

Both men and women
35-54 age

Risks:
- Age
- Repetitive risk felxion activities
- Occupation with repetitive heavy lifting

35
Q

Signs and symptoms of tennis elbow

A
  • Pain on palpation on and around the lateral epicondyle
  • Present gradually
  • Pain and weakness on resisted wrist extension
  • Aggrs: gripping, lifting
  • Positive Maudsleys, Mills and cozens
36
Q

Golfers elbow: pathophysiology and risk factors

A

Overuse injury cause by overload at the origin of the common flexor tendon
- Leading to tendinosis and inflammation of associated tendons

Men and women
35-54 years

Risks:
- Repetitive elbow movement activities especially flexion
- Sports involving gripping and throwing

37
Q

Signs and symptoms of golfers elbow

A
  • Tenderness on palpation of medial epicondyle
  • Aggrs factors: gripping, lifting, activities involving wrist flexion
  • Present gradually
    -Pain and weakness on resisted wrist flexion
38
Q

Management of golfers and tennis elbow

A
  • Education
  • Advise on heat/ice for pain relief
  • Rest from aggrs factors
  • Direct to GP

if symptoms dont improve 6/52:
- Physio for stretnching and strengthening
- Only injecting in severe cases
- No improvement after 6-12 months consider surgery

39
Q

Cubital tunnel: Pathophysiology and risk factors

A

Peripheral entrapment neuropathy affecting the ulna nerve as it courses through the medial elbow region
- caused by pressure or traction, trauma, pathologies (RA, OA, tumours, fractures)

2 times more likely in men

Risks:
Occupations involving repetitive elbow flexion and extension movements
Prolonged leaning on elbows
Obesity
Diabetes
Over 40 yrs

40
Q

Signs and symptoms of cubital tunnel

A

-Pain, numbness and tingling in the ulnar nerve sensory distribution
-Weakness with gripping activities and in chronic cases can describe loss of fine dexterity
-Tenderness surrounding the medial epicondyle and cubital fossa
-Aggr factors: leaning on the elbows (medial aspect) or by flexion and extension of the elbow
-Weakness of muscles innervated by ulnar nerve
-Positive tinnels and froments sign

41
Q

Management of cubital tunnel

A
  • Education
  • Activity modification
  • Elbow splinting or wrapping elbow to avoid excessive flexion
  • Consider epiclasp elbow strap (4-6 weeks)
  • Direct to GP

No improvement:
Physiotherapy for joint mobs, stretching and neural mobilisation
In severe cases surgery

42
Q

What are the red flags to look out for when assessing the shoulder/elbow?

A
  • Osteosarcoma
  • Acute rotator cuff tear
  • Polymyalgia Rheumatica
  • Giant cell arthritis
  • AVN of humeral head
  • DVT in upper limb
  • Loosening/infection

Year 2- MSK (10 decks)

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