SHOULDER CLAVICLE BRACHIAL DISORDERS Flashcards
1
Q
rotator cuff muscles
A
Subscapularis (anterior)
Supraspinatus (posterior)
Infraspinatus (posterior)
Teres minor (posterior)
2
Q
shoulder muscles
A
Rotator Cuff Muscles = Supraspinatus, Infraspinatus, Teres Minor, Subscapularis Pec Major Biceps Deltoid Trapezius Serratus Anterior Rhomboid
3
Q
shoulder conditions
A
Trauma Over-use Instability Fractures Age-related processes Nerve injuries
4
Q
AC SEPARATION / AC JOINT DISLOCATION / SHOULDER SEPARATION
A
- Typically as a result of falling directly on the tip of the shoulder; direct blow to adducted shoulder
- Acromioclavicular joint separation (possibly along with coracoclavicular joint); due to sprain or actual rupture
5
Q
grades I-III of AC separation
A
Grade I = AC ligament sprain; have a normal CXR
Grade II = AC ligament rupture & CC ligament sprain (Coracoclavicular ligament); have slight widening on CXR
Grade III = AC & CC ligament rupture; have significant widening on CXR
6
Q
AC ligament rupture & CC ligament sprain (Coracoclavicular ligament); have slight widening on CXR
A
grade II AC separation
7
Q
AC & CC ligament rupture; have significant widening on CXR
A
grade III AC separation
8
Q
AC ligament sprain; have a normal CXR
A
grade I AC separation
9
Q
CLINICAL PRESENTATION OF AC JOINT SEPARATION
A
- pain with lifting arm & unable to lift arm @ shoulder
- tenderness at the AC joint
- may or may not have a deformity at the AC joint
- pain with ADDUCTION of the shoulder (putting arm back down)
10
Q
what tests are positive with AC separation
A
+ cross arm test
+ Paxinos test
11
Q
cross arm test = tests
A
AC joint disorder
12
Q
AC Separation treatment
A
- brief sling immobilization (x 1-2 weeks)
- Rest, Ice, NSAIDS
- The return to play / activity is determined by the patient’s comfort level
- Weaver-Dunn procedure = if pain persists despite conservative management = take coracoacromial ligament to reconstruct the CC ligament
13
Q
what is the Weaver-Dunn procedure and when is it performed
A
if pain persists despite conservative management for shoulder joint separation = take coracoacromial ligament to reconstruct the CC ligament
14
Q
most common location for clavicular fracture
A
mid-shaft
medial clavicular fracture = uncommon
15
Q
CLAVICLE FRACTURE MOA
A
- Similar mechanism of injury as AC joint separation, except the energy passes through bone instead of a ligament, causing a fracture
- mid / high energy impact to the area
- MC in males
- in children < 2 = suspect child abuse
- Also rarely treated with surgery, just like AC joint separation
16
Q
**MC fractured bone in children, adolescents, and newborns (during birth)
A
CLAVICLE
17
Q
clinical findings of clavicular fracture
A
⦁ tenderness to palpation over clavicle fracture site
⦁ pain with adduction of the shoulder (just like with AC joint separation)
⦁ patient will be sitting with shoulders rolled forward
⦁ deformity at fracture site - possible “TENTING” of the skin
18
Q
figure of 8 sling
A
for clavicle fracture
19
Q
clavicle fracture treatment
A
- Rest, Ice, NSAIDS
- sling for comfort - figure-of-8 sling in children
- return to activity in about 8 weeks
- rarely treated with surgery; may be needed if significant displacement
20
Q
what is rotator cuff tendonitis
A
- overuse injury
- most common in adults in 4th-5th decades of life; also seen in throwing athletes (pitchers)
- often the result of inability to train appropriately during off season for athletes
MOA = inflammation of the cuff tendon
rotator cuff tendonitis = rotator cuff tendinopathy = rotator cuff bursitis
- RC tendonitis = inflammation usually associated with sub-acromial bursitis
***MC rotator cuff tendon injury = Supraspinatus
21
Q
most common tendon injured/torn in rotator cuff
A
supraspinatus
22
Q
clinical presentation of rotator cuff tendonitis
A
⦁ development of pain after an aggravating activity, such as painting the house
⦁ pain can be insidious without specific injury
⦁ localized to the anterior lateral aspect of the shoulder
⦁ pain = worse with reaching overhead or behind the body
⦁ pain at night - difficulty sleeping
⦁ patients grab deltoid, but this is not an issue with the deltoid muscle, but that the pain is radiating down from the rotator cuff to the deltoid
23
Q
BOARD QUESTION = shoulder pain + can’t sleep
A
rotator cuff injury!!!!!
24
Q
supraspinatus strength test
A
empty can test
25
impingement tests for subscapular nerve / supraspinatus
Hawkins & Neers test
26
rotator cuff tendonitis PE
- tenderness to palpation over the greater tuberosity or bicipital groove
- full range of motion, but painful arc of motion and elevation
- pain with resisted supraspinatus testing
- no weakness on exam
⦁ + Hawkins test - tests impingement of subscapular nerve/supraspinatus (chicken wing)
⦁ + Neers test - tests impingement of subscapular nerve/supraspinatus (arm straight up)
- hold shoulder down on patient to prevent shrugging
⦁ + drop arm test = pain with inability to lift arm above shoulder level, and severe pain when lowering arm after shoulder is abducted
Since most common location = supraspinatus = can do empty can test = supraspinatus strength test
27
rotator cuff tendonitis treatment
⦁ Rest, ice, NSAIDS, maybe stop the offending activity
⦁ PT for rotator cuff strengthening exercises
⦁ can do subacromial steroid injections if not improving or if pain severe at night
- if still not getting better = may have a rotator cuff tear instead of tendonitis
28
external rotation of shoulder with elbow bent at 90 = strengthens____________
infraspinatus & teres minor
29
internal rotation of shoulder with elbow bent at 90 = strengthens _______________
subscapularis
30
arm straight out at 30 degrees in front of you & pronated = strengthens _____________
supraspinatus (empty can test)
31
ROTATOR CUFF TEAR
- Most commonly a degenerative process, with tears occurring as a result of breakdown of the tendon and eventual wearing out
32
MC torn rotator cuff tendon
Supraspinatus
then infraspinatus, then subscapularis
33
Rotator cuff tendon more commonly torn as a result of trauma
Subscapularis
34
rotator cuff tear = very uncommon before age
30
35
RISK FACTORS FOR TORN ROTATOR CUFF
⦁ Age
⦁ Smoking
⦁ Fall
36
main difference between rotator cuff tendonitis vs tear
WEAKNESS with tear
37
clinical presentation of rotator cuff tear
similar to rotator cuff tendonitis)
- pain with reaching overhead
- ****NIGHT PAIN****
- ****WEAKNESS****
- pain over anterior lateral aspect of shoulder
- pain radiates to the deltoid insertion - so pts often holding on to their deltoid
- pain can be insidious, or as a result of trauma, such as a fall or after lifting something
- may have felt a pop or tearing sound at time of injury
38
CLINICAL EXAM OF ROTATOR CUFF TEAR
- similar exam to tendonitis, with exception of WEAKNESS of affected rotator cuff (tendonitis = just pain, but tear = both pain + weakness)
- FULL PASSIVE ROM, but limited active ROM (whereas tendonitis = full range of motion)
⦁ Weakness in external rotation = Infraspinatus tear
⦁ Weakness with empty can = Supraspinatus tear
⦁ Weakness with internal rotation = Subscapularis
⦁ + Neers Test
⦁ + Hawkins Test
⦁ Lift off test & Belly Compression test = tests Subscapularis
⦁ Bear Hugger Test = tests subscapularis too
Xray may have subtle findings, but most of the time = negative
- would see disruption of shenton's line
39
internal rotation muscles
subscapularis + pec major
| so internal rotation tests - test subscapularis tendon with rotator cuff injuries
40
treatment for rotator cuff tear
- Rest, Ice, NSAIDS
- PT for rotator cuff strengthening
- Subacromial steroid injection
- MRI to evaluate size of rotator cuff tear or to rule it in
- surgical repair of rotator cuff (if severe)
41
MC tendon with calcific tendonitis
supraspinatus
42
calcific tendonitis
- deposition of calcium "hydroxyapatite" in rotator cuff tendon
- MC tendon of calcium deposition = Supraspinatus
- different consistency in different phases
⦁ During Liquid / tooth paste phase = more painful & inflammatory
⦁ During chalk consistency phase = more dormant, no inflammation
VERY PAINFUL - not as much with passive ROM, but extremely painful with active ROM
43
clinical presentation of calcific tendonitis
- can be insidious in onset, or can have sudden development of severe "white knuckle pain"
- pain with any movement of the shoulder
- unable to sleep due to pain
44
clinical exam for calcific tendonitis
- tenderness over greater tuberosity
- limited active ROM due to pain
- pain with firing of rotator cuff
- full passive ROM not as painful as active ROM
- weakness of cuff is due to pain only - NO TRUE WEAKNESS (unlike rotator cuff tear)
45
calcific tendonitis treatment
- NSAIDS, ice, rest
- PT can be done to prevent stiffness, but not typically helpful
- Subacromial steroid injection with Needling of calcium deposit (use needles to suck calcium deposits out of the tendon)
- Surgical decompression and debridement of calcium deposit
46
liquid / tooth paste phase vs chalk consistency phase of calcific tendonitis
⦁ During Liquid / tooth paste phase = more painful & inflammatory
⦁ During chalk consistency phase = more dormant, no inflammation
47
ADHESIVE CAPSULITIS
= "Frozen Shoulder" = loss of motion of the shoulder as a result of tightening and shrinking of the shoulder capsule (joint capsule)
- may follow a trauma to the shoulder
48
Cause of adhesive capsulitis
idiopathic
- may follow a trauma to the shoulder
49
Risk factors of adhesive capsulitis
RISK FACTORS
⦁ Female
⦁ Diabetic
⦁ Hypothyroidism
- usually in the 50's+
- think its therefore hormonally related
50
3 phases of adhesive capsulitis
⦁ Freezing - painful
⦁ Frozen - stiff
⦁ Thawing - getting better slowly
51
CLINICAL PRESENTATION OF FROZEN SHOULDER
⦁ insidious onset of pain & progressive loss of motion
⦁ may follow a trauma, but normally idiopathic
⦁ pain at end range of motion
⦁ night pain
⦁ can't reach into back pocket
52
CLINICAL EXAM OF ADHESIVE CAPSULITIS
⦁ loss of both passive & active ROM
| ⦁ pain at end range of motion
53
TREATMENT OF ADHESIVE CAPSULITIS
- PT to work on capsular stretching
- glenohumeral steroid injection in early stages to decrease inflammation of the capsule
- manipulation under anesthesia
- arthroscopic capsular release - surgery
54
LABRAL INJURY
- injury to the soft tissue cartilage ring around the socket of the shoulder which provides stability to the shoulder
- common in throwers as an overuse injury, or traumatic in football, wrestling, volleyball, tennis
55
clinical presentation of labral injury
- common complaint = "painful pop" in the shoulder
- difficulty throwing a ball
- mild sense of instability
56
most common labral tear
SLAP tear = superior labral, anterior to posterior
57
TEST FOR LABRAL TEARS
OBRIEN TEST - for SLAP tear
⦁ Obrien test will be positive for impingement (rotator cuff tendonitis / rotator cuff tear) too, but if everything else is negative (neer / hawkins / empty can etc) and positive Obrien test, and right patient demographic - young athlete = more likely Labral Tear
Obrien test = arm straight out, pronated, and adducted across body
58
exam for labral injury
- full range of motion
- crepitus with internal & external rotation
- POSITIVE OBRIEN TEST = SLAP tear
⦁ Obrien test will be positive for impingement (rotator cuff tendonitis / rotator cuff tear) too, but if everything else is negative (neer / hawkins / empty can etc) and positive Obrien test, and right patient demographic - young athlete = more likely Labral Tear
59
treatment for labral injury
- conservative - no significant time off is needed from sports
- PT for rotator cuff strength and stabilization
- if pain persists despite conservative measures = surgical repair
60
IMPINGEMENT
- Posterior impingement is common in throwers due to increased laxity to the anterior shoulder capsule during cocking phase of throwing & tightness in the back
- most will complain of pain in the back of shoulder that is worse while throwing
- treated with aggressive stretching program for the anterior capsule of the shoulder, and strength program for the rotator cuff
* *Due to lax anterior capsule but tight posterior capsule - pain in back of shoulder that is worse when throwing
- have increased external rotation, but decreased internal rotation
POSTERIOR IMPINGEMENT
- over stretch of the anterior capsule in the cocking phase (laxity of anterior capsule - so able to hyperextend backwards)
- pain & impingement occurs in the acceleration and deceleration phase (due to tightness of posterior capsule - hurts when moving arm forward till release)
61
impingement problems due to _______ of anterior capsule and _________ of posterior capsule
lax anterior capsule
| tight posterior capsule
62
which shoulder dislocation is more common
anterior
63
shoulder dislocation occurs most often due to
occurs most often due to elevation & external rotation of the shoulder (arm cocked in upward 90 degree angle, then hit)
64
can occur as a result to seizure & electrocution
posterior dislocation (more common to get anterior dislocation, but for testing purposes - if person has a seizure or is electrocuted / tasered = posterior dislocation)
65
ANTERIOR DISLOCATION = worried about ____ nerve
axillary
| - can end up losing sensation in deltoid muscle - need to pop humerus back in asap
66
********if pt has dislocated their shoulder, the pt has a
torn rotator cuff until proven otherwise
67
CLINICAL EXAM OF ANTERIOR DISLOCATION
⦁ + Apprehension sign
⦁ + Relocation test
⦁ Increased anterior translation
⦁ Pain with range of motion, and guarding with reached overhead
68
TREATMENT OF ANTERIOR DISLOCATION OF SHOULDER
- 1st time dislocation = reduction of dislocation & early immobilization
- PT to work on shoulder stabilization with rotator cuff strengthening
- if continue to have recurrent dislocations = surgery
- need to do XRAY to check for Bony Bankart (glenoid fracture) and Hillsach's deformity
- return to play about 4-6 weeks later; may require bracing to prevent re-dislocation
- MRI of shoulder if 50+ to rule out rotator cuff tear
69
fracture of the glenoid cavity
Bony Bankart
- glenoid inferior rim fracture
70
posterolateral humeral head compression fracture, typically secondary to recurrent anterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid.
Hill sachs deformity
- compression fracture on humeral head from impact against glenoid
71
with anterior dislocations = want to do xray to confirm no
bony bankart or hill sachs deformities
72
POSTERIOR SHOULDER DISLOCATIONS
- less common than anterior; remember to think seizures / electrocution
- treated conservatively with reduction and immobilization
- PT to work on rotator cuff strength exercising
- bracing may help with prevention
- recurrent dislocation = requires surgery to stabilize
Posterior dislocations = most common in football linemen due to blocking or being blocked
- the shoulder gets forced out the back by getting struck in the shoulder, or by blocking an immovable object
- can also occur with MVA, seizures, or electrocutions
73
with anterior shoulder dislocation = must rule out
AXILLARY NERVE INJURY - get pinprick sensation over deltoid
74
diagnosis of anterior dislocation
axillary & "Y" view
75
appearance of posterior shoulder dislocation
- arm is adducted and internally rotated
| - anterior shoulder is flat, and humeral head is prominent posteriorly
76
multi-joint laxity
SHOULDER MULTIDIRECTIONAL INSTABILITY
77
SHOULDER MULTIDIRECTIONAL INSTABILITY
- may have multi-joint laxity
- report recurrent shoulder dislocations, but have never had to go to the ER to have shoulder reduced
- will also complain of a dull ache in the shoulder
Have loose, saggy joint capsule. Can contort their arm or dislocate their arm
78
SHOULDER INSTABILITY TREATMENT
- aggressive PT to strengthen scapular stabilizers as well as the rotator cuff
- surgery = last treatment option
79
glenohumeral osteoarthritis isn't as common as knee or hip OA because
the shoulder is a non-weight bearing joint
80
risk factors for shoulder OA
⦁ previous trauma such as dislocation
⦁ instability issues
⦁ hereditary
⦁ heavy laborer
81
CLINICAL PRESENTATION OF SHOULDER OA
- insidious onset of shoulder pain - located anterior lateral or posterior
- pain is typically achy with sharp overtones
- loss of range of motion - may not be obvious to the patient
- pain at end range of motion with sudden movement
82
CLINICAL EXAM OF SHOULDER OA
- loss of range of motion, especially external & internal rotation
- normal strength
- crepitus with range of motion of glenohumeral joint - "cogwheeling" (also occurs with labral tear)
- tender over the anterior and posterior capsule of the shoulder
83
SHOULDER OA TREATMENT
⦁ NSAIDS, Tylenol (while NSAIDS work better, tylenol = preferred initial tx in elderly with bleeding risk and mild/mod dz)
⦁ Terminal stretching to prevent further stiffness
⦁ Glucosamine / Chondroitin
⦁ Activity modification
⦁ Glenohumeral steroid injection
⦁ Total shoulder replacement
84
PARSONAGE TURNER SYNDROME
cause unknown
- brachial plexus neuritis or neuralgic amyotrophy - inflammation of a network of nerves that innervate the muscles of the chest / shoulders / arms = "suprascapular nerve"
may experience paralysis of affected areas for months, or in some cases, years, but recovery is usually eventually complete
85
PARSONAGE TURNER SYNDROME paralyzes the ____________ nerve
suprascapular nerve = paralyzed
this nerve innervates supra and infraspinatus
86
CLINICAL PRESENTATION OF PARSONAGE TURNER SYNDROME
⦁ first experience severe pain across the shoulder and upper arm
⦁ within a few hours to days = weakness, wasting (atrophy) & paralysis may affect the shoulder muscles
- the supraspinatus and infraspinatus muscles start to atrophy - can start to feel the spine of the scapula on the back
- can take a year or two to get back to normal strength
87
CLINICAL EXAM OF PARSONAGE TURNER
- atrophy of supraspinatus & infraspinatus muscles
- significant weakness of affected muscles
- usually non-tender
- if in acute phase, the patient may not tolerate palpation - in extreme pain
88
TREATMENT OF PARSONAGE TURNER
ORAL CORTICOSTEROIDS*******
- EMG or MRI studies may be helpful to exclude cervical radiculopathy, or rotator cuff tear
- ***ORAL CORTICOSTEROIDS***
- neurontin
- pain meds
- PT
89
***usually follows an upper respiratory infection (but can also occur after vaccinations)
PARSONAGE TURNER SYNDROME
90
"popeye"
long head biceps rupture
91
"scapular winging"
long thoracic nerve injury
92
women are prone to _______________ with age
proximal humerus fractures
93
injury prevention
- Most overuse shoulder injuries can be prevented with strengthening and stretching programs
- Unfortunately many of the exercises necessary to prevent shoulder injury are neglected during routine strengthening work outs and lifting programs.
94
SUPRASPINATUS EXERCISES
- empty can exercises with thumb down - can be performed with light dumbbells or rubber tubing
95
ROTATOR CUFF EXERCISES
- the rotator cuff muscles are not significantly large, and don't carry the notoriety of other muscles of the body, such as the pec major
- it is important to add rotator cuff strengthening programs to the daily regimen of athletes to prevent injury from occurring
96
INFRASPINATUS & TERES MINOR EXERCISES
- cable or rubber tubing exercises to externally rotate - with elbow at side, arm externally rotates against resistance
97
strongest rotator cuff muscle
subscapularis
98
SUBSCAPULARIS EXERCISES
- strongest of the rotator cuff muscles
- best strengthened with cables or rubber tubing
- internal rotation
99
STRETCHING PROGRAMS
- remember that the shoulder needs balance; too much strength on one side may lead to instability or impingement on the other
- stretching = key to shoulder function, yet it goes overlooked in many work out programs
100
disruption of shenton's line
rotator cuff tear
101
cystic changes to greater tuberosity of the humerus
chronic rotator cuff disease
