Shoulder Clavical Brachial Disorders Flashcards
AC Separation
- Mechanism of injury (MOI)
- What ligaments are disrupted?
- Clinical findings
- Tx
MOI
-falling directly on the tip of the shoulder (hockey player getting checked into the boards)
Ligaments
-coracoclavicular ligaments and acromioclavicular ligament
Clinical findings
- tenderness at AC joint
- possible deformity at AC joint
- pain with ADduction of the shoulder
- cross arm test
- Paxinos test with anterior and posterior instability
- pain with doing a dip
Tx
- Rest, ice, NSAIDs
- sling for comfort for a week or two
- rarely surgery: Weaver-Dunn procedure (reconstruction of CC ligament) if pain is persisting despite conservative management
Clavicle Fracture
- MOI
- Clinical findings
- Tx
MOI
-similar to AC joint separation (falling directly on the tip of the shoulder) only the energy passes through the bone causing a fracture
Clinical findings
- tenderness to palpation over the fracture of the clavicle
- pain with ADduction of the shoulder
- Pt will be sitting with shoulders rolled forward
- possible tenting of the skin
Tx
- Rest, ice, NSAIDs
- sling for comfort
- return to activity is roughly 8 weeks
- surgery if significant displacement (plate and screws)
Rotator Cuff Tendonitis
- type of injury
- MC in who
- what is this
- presentation
- clinical exam
- tx
Type of injury
-overuse injury
MC in adults in 4th-5th decades, but also in throwers
What
-inflammation of the cuff tendon, degenerative fraying, bursitis
Presentation
- development of pain after an aggravating activity such as painting the house, but pain can be insidious without specific injury
- localized to the anterior lateral aspect of the shoulder
- pain is worse with reaching overhead or behind the body
- pain at night, difficult to sleep***
Clinical Exam
- tenderness to palpation over the greater tuberosity or bicepital groove
- painful arc of motion and elevation
- full ROM
- pain with resisted supraspinatis testing
- NO WEAKNESS on exam
- Hawkins, + Neers impingement sign
Tx
- 6 weeks of rest*
- graduated throwing program
- PT for rotator cuff strengthening
- subacromial steroid injection
What is the Hawkins Impingement Sign? Neers?
Hawkins- “hawk wing”
-The patient is examined while sitting with their shoulder flexed to 90° and their elbow flexed to 90°. The examiner grasps and supports proximal to the wrist and elbow to ensure maximal relaxation, the examiner and the patient then quickly rotate the arm internally. Pain located below the acromioclavicular joint with internal rotation is considered a positive test result.
Neers
-When your arm is fully raised overhead, have your partner push your arm up even further. He should use one hand on your arm and the other hand supporting your shoulder blade.
Rotator Cuff Tear
- type of injury
- MC tendon torn
- risk factors
- clinical presentation
Type of injury
-most commonly a degenerative process with tears occurring as a result of breakdown of the tendon and eventual wearing out
MC tendons torn
- supraspinatus and 2. infraspinatus
- subscapularis more commonly torn as a result of trauma
Risk factors
- age (RARE under age 30), smoking, fall
- “you have to be old to have one!”
Clinical Presentation
- similar to rotator cuff tendonitis
- pain with reaching overhead, night pain, cannot get comfortable lying on shoulder, WEAKNESS, difficulty reaching overhead, pain over anterior lateral aspect of the shoulder
- pain radiates to the deltoid insertion
- may have felt a pop at the time of injury
- may be sudden or insidious
Rotator Cuff Tear
- Clinical exam
- special tests
- tx
Clinical exam
- similar to tendonitis with exception of WEAKNESS
- Full passive ROM but limited active ROM
- weakness in external rotation=infraspinatus tear
- weakness with empty can=supraspinatus tear
- weakness with internal rotation= subscapularis tear
- xray most likely negative
Special tests
- bear hugger=subscapularis
- lift off test= subscapularis
- belly compression test= subscapularis
- Hawkins, + Neers
Tx
- Rest, ice, NSAIDs
- PT for RC strength
- subacromial steroid injection
- surgical repair of the rotator cuff
Calcific Tendonitis
- What is this
- course
- presentation
- clinical exam
- Tx
What
-deposition of calcium “hydroxyapatite” the rotator cuff tendon (supraspinatus MC)
Course
- liquid/toothpaste consistency phase: more painful and inflammatory
- Chalk consistency phase: more dormant and no inflammation
Presentation
- can be insidious or sudden
- SEVERE “white knuckle” pain
- pain with any movement of the shoulder
- unable to sleep due to pain
Clinical Exam
- tenderness over the greater tuberosity
- limited active ROM (secondary to pain)
- pain with firing the rotator cuff
- full passive ROM that is not as painful as active ROM
- weakness of the cuff due to pain only, no true weakness
Tx
- NSAIDs, rest, ice
- PT to prevent stiffness, but typically not that helpful
- subacromial steroid injection with needling of Ca deposit
- surgical decompression and debridement of Ca deposit
Adhesive Capsulitis
- AKA
- what is this
- risk factors
- cause
- phases
AKA
-frozen shoulder
What
-loss of motion of the shoulder as a result of tightening and shrinking of the shoulder capsule
Risk factors
-Female, DM, hypothyroid
Cause
- idiopathic
- may follow trauma to the shoulder
Phases
-freezing (no limited ROM but pain at rest), frozen (no pain at rest but limited ROM), thawing (can take up to two years)
Adhesive Capsulitis
- Clinical presentation
- clinical exam
- Tx
Clinical Presentation
- insidious onset of pain and progressive loss of motion
- pain at the end of ROM
- night pain (referred to the elbow)
- cant reach into back pocket
Clinical exam
- Loss of both passive and active ROM
- pain at end of ROM
Tx
- PT for capsular stretching
- GLENOHUMORAL steroid injection in early stages to decrease inflammation of the capsule
- manipulation under anesthesia “tear adhesions and capsule”
- arthroscopic capsular release
Labral Injuries/tear
- common in who
- what is this
- what is the a common site
- clinical presentation
- clinical exam
- Tx
Common in
- throwers as an overuse injury
- young people
What
-injury to the soft tissue cartilage ring around the socket of the shoulder which provides stability to the shoulder
A common site: SLAP
-superior labral, anterior-posterior
Clinical presentation
- “painful pop”
- difficulty throwing a ball
- some mild sense of instability
Clinical exam
- fill ROM, crepitus with internal and external rotation
- Obrien test=SLAP tear
Tx
- conservative with no significant time off needed from sports
- PT for strength and stabilization of the RC
- persistent pain may require surgery
What is the Obrien test?
The arm to be tested should be in 90 degrees of flexion and about 10 degrees of adduction. The patient then internally rotates the arm, pronating at the elbow and essentially pointing the thumb to the ground.
The examiner provides a downward force distally on the arm while the patient resists with an upward force.
The test is considered positive if there is pain and/or clicking when the arm is in full internal rotation but not when the arm is in neutral rotation.
Impingement Problems: posterior impingement
- common in who
- cause
- MC complaint
- tx
Common in
-throwers
Cause
- increased laxity to the anterior shoulder capsule during cocking phase of throwing and tightness in the back
- -(over stretch of the anterior capsule, pain and impingement occurs in the acceleration and deceleration phase)
MC complaint
-pain in the back of the shoulder worse while throwing
Tx
-aggressive stretching program for the anterior capsule of the shoulder and strength program for the RC
Shoulder dislocation
- MOI
- is anterior or posterior more common?
- MC cause for posterior dislocation
MOI
-occurs due to elevation and external rotation of the shoulder
Anterior dislocation is much more common than posterior dislocation
Posterior dislocation is more common in football linemen due to blocking position, also seizure and electrocution***
Anterior Shoulder Dislocation
- clinical presentation
- clinical exam
- tx
Clinical presentation
- pain following an injury
- felt a pop and sensation of dislocation with significant pain
Clinical exam
- apprehension sign
- +relocation test
- increased anterior translation
- pain with ROM and quarding with reaching overhead
Tx
- Xray to rule out anterior/inferior glenoid fx “bony bankart” or hillsachs deformity
- MRI if over 50 years old to rule our RC tear
- reduction and early immobilization
- PT for strength and stabilization
- return to play 4-6 weeks, may require brace
Posterior Shoulder Dislocation
- MC mechanism
- tx
MC in lineman due to blocking or being blocked
-also MVA, seizure, or electrocution
Tx
- conservatively with reduction and immobilization
- PT
- bracing may help with prevention
- recurrent dislocations require surgery to stabilize
