Shoulder Common Clinical Presentations Flashcards
FRACTURES
FRACTURES
- Fractures of the proximal humerus make up __% of fractures in the appendicular skeleton.
- They are commonly referred to as FOOSH, what is this?
- 5%
- Fall on outstretched hand
What populations are at risk for fractures of the proximal humerus?
- children (growth plate)
- older adults (osteopenic/osteoporotic bone)
- In what instance is the fracture of the proximal humerus managed conservatively?
- In what instance must a patient with a fracture of the proximal humerus undergo surgery?
- When it is nondisplaced and stable
- When they have poor outcome or increased risk for complications (ORIF)
What are some risk factors that indicate a poor outcome of a proximal humerus fracture?
- severe osteoporosis
- smoking
- drug and alcohol abuse
- DM
- RA
- immunocompromise including steroid meds and concurrent neoplasm
What is Neer’s Classification?
A way to classify different proximal humerus fractures.
What neurovascular structures tend to be injured with proximal humerus fractures?
- Circumflex humeral artery
- Axillary nerve
- Fractures of the clavicle make up __-__% of all fractures in the appendicular skeleton.
- They are commonly related to _______ injury/ direct ________.
- 5-10%
- FOOSH injury/ direct trauma
- What percentage of clavicle fractures occur at the distal portion?
- What percentage of clavicle fractures occur at the middle portion?
- What percentage of clavicle fractures occur at the proximal portion?
- Distal = 16.6%
- Middle = 81.3%
- Proximal = 2.1%
Why do we want to consider where a clavicle fracture has occured?
- Fragments can damage structures (subclavien artery, brachial plexus)
- Callus formation can also compress on neurovascular structures
- Fractures can heal out of alignment also causing impingement/compression
How would a patient with a clavicle fracture present during a physical examination?
- guarded shoulder motion
- supporting UE with contralateral UE (holding as if in shoulder sling)
- deformity
- extreme tenderness
- signs consistent with secondary brachial plexus injury (weakness/sensory dysfunction)
SC AND AC JOINT INJURIES
SC AND AC JOINT INJURIES
__% of shoulder girdle injuries happen at the SC joint. 80% of these are _____ or ____ related.
- 3%
- sport or MVC
What is the mechanism of SC joint injuries?
Shoulder forced anteriorly or medially (blow to posterior shoulder)
SC Sprains most common:
- Mild: ______ joint _______ ligament integrity compromise
- Moderate: ________ joint with _________ ligament compromise
- Severe: _______ joint with _________ ligament disruption
- stable, without
- subluxed, partial
- unstable, complete
How would a SC joint injury present?
- observable deformity
- local tenderness
- pain with shoulder motion (elevation especially)
__-__% of acute shoulder injuries are AC joint injuries. (up to 40% for athletes)
9-10%
What is the mechanism of AC joint injuries?
fall, sport or MVC related
What are the 2 ligaments that can be compromised during an AC joint injury? What kind of stability is compromised with each?
- AC ligament- compromised horizontal stability
- CC ligament- compromised vertical stability
The classification system for AC joint injuries is based on the extend of ________ displacement.
clavicular
How would a AC joint injury present?
- Shoulder weakness (AROM or resistive)
- Local tenderness (+ AC joint palpation test)
- Possible deformity
- Possible swelling
- Pain with shoulder movement
How many AC separation types are there?
6
- Type I AC separation involves a sprain of the ___ ligament.
- Type II AC separation involves rupture of the ___ ligaments and sprain of the ____ ligaments.
- AC
- AC, CC
What does treatment of type I and II AC joint separations look like?
- typically brief period of immobilization/sling use (1-2 weeks)
- gentle ROM, isometric exercises
- progression to scap stab exercises
Type III AC separation involves rupture of the ___ and ____ ligaments and detachment of the _______ and __________ muscles.
- AC and CC
- deltoid and trapezuis
Type III AC separation can be treated ________ or _________.
surgically or conservatively
What does treatment of Type III AC joint separations look like?
- sling immobilization (full PROM 2-3 weeks after immobilization)
- progressive shoulder strengthening
- RTS (return to sports) 6-12 weeks
- reconstruction if limitations persist >/= 3 months
- Type IV AC separation involves the rupture of all supporting structures and the clavicle is displaced in or through the ___________.
- Type V separation involves the rupture of all supporting structures and is a more severe form of type ___.
- Type VI separation involves the rupture of all supporting structures and the distal clavicle being displaced behind tendons of _________ and ____________.
- trapezius
- III
- biceps and coracobrachialis
Types IV, V, and VI are _________ managed and we see them _________.
- surgically
- post-op
What does treatment of Type IV, V, and VI AC joint seperations look like?
- progress toward full ROM, f/b strengthening exercises
- manual therapy interventions as appropriate
- scap stab/ proprioceptive training progress
SCAPULAR DYSKINESIA
SCAPULAR DYSKINESIA
What is scapular dyskinesia?
Abnormal mobility or function of the scapula.
What 3 things are present in scapular dyskinesia?
- motion abnormalities
- mechanical neck and shoulder pain
- diminished soft tissue extensibility
What motion abnormalities are present in scapular dyskinesia?
- diminished posterior tilting, upward rotation, and clavicle retraction
- excessive clavicle elevation
Mechanical neck and shoulder pain comes from hyperactive _________. Also may come from impaired motor function of the _____________ as well as ____________.
- upper trap
- lower and mid traps as well as serratus anterior
In scapular dyskinesia we see diminished soft tissue extensibility of what structures/muscles?
- pec minor
- posterior shoulder/capsule
- levator scap, lats, GH external rotators
RCT INJURY
RCT INJURY
What can cause subacromial impingement?
- Excessive superior translation of humeral head with elevation
- Overuse of the shoulder causing microtrauma leading to inflammation
What structures can be impinged in subacromial impingement?
- rotator cuff tendons
- subacromial bursa
- long head of biceps tendon
- coracoacromial ligament
> __ years old is increased risk for rotator cuff tendinopathy.
40
- Over time, microtrauma of a tendon can lead to _________.
- Are females or males at increased risk for this?
- What is the mechanism though to cause this?
- calcification
- females
- hypoxia
What is tendonitis?
Tendon pain caused by inflammation.
What is tendinosis?
Microtrauma that results in degeneration or breakdown of a tendons collagen. (Chronic)
What are some abnormalities that can cause subacromial impingement?
- anatomical abnormalities of acromion
- bursitis
- calcified bone spur
- tendon thickening
- altered scapulathoracic/scapulohumeral kinematics
- postural abnormalities
- superior translation of humeral head during elevation (decreased GH stability, tight posterior capsule)
What is the typical clinical progression of rotator cuff tendinopathy?
- tendonitis
- degenerative tendinosis
- partial thickness tear
- full thickness tear
What are the symptoms of rotator cuff tendinopathy?
- dull ache lateral upper/lower arm
- reaching away from body painful
- over shoulder-level activities
Rotator Cuff Tendinopathy Physical Exam Findings:
- common pain distribution in the ______ _______ upper arm
- possible painful ___ (__°-__°)
- weakness, pain with ______/______/_______
- tender at insertion tendon
- ___________ peri-scapular musculature
- altered scapular kinematics (diminished __________ and _____________ with excessive ____________)
- pec minor _________
- decreased __________ capsule length
- muscle performance impairments of the ______________ and _______________
- lateral proximal upper arm
- arc (60°-120°)
- AROM/resistance testing/passive stretching
- muscle guarding
- diminished post tilting and upward rotation with excessive IR
- “tightness”
- posterior
- serratus anterior and lower trap
- What is the glenohumeral painful arc?
- What is the acromioclavicular painful arc?
- 60°-120°
- 170°-180°
With rotator cuff tears, what 4 things do we want to consider?
- size
- location
- direction
- depth
Does surgical or conservative intervention of partial/full tendon tears have better long-term outcomes?
They are comparable
Rotator Cuff Tear Physical Exam Findings:
- findings described for RC _____________
- significant __________ with shoulder
- compensation with __________ motion when attempting to elevate UE
- tendinopathy
- weakness
- scapular
After the age of 60 about __% are thought to have shoulder pathologies.
50%
Risk For Rotator Cuff Injury in the Older Adult:
- tissue changes with normal physiological ______
- “_______ _______”
- fatty infiltration of ___________ and ________ muscles
- aging
- “critical zone”
- supraspinatus and infraspinatus
What is rotator cuff critical zone?
Portion of supraspinatus that is now no longer vascular, not allowing repair.
Older patients also present with ________ changes and may have ________ and ___________ impairements.
- postural
- memory and cognitive
BICEPS TENDON INJURY
BICEPS TENDON INJURY
Biceps tendon lesion can be related to a _______ or a __________.
tendinosis or tendonitis
Biceps tendon instability is associated with ______ lesion. It is also commonly associated with ______ tears and ______ lesions.
- pulley lesions
- subscap tears and SLAP lesion
Biceps Tendon Lesion Tendinopathy:
- Initial __________ response f/b ________ process
- mechanism= ___________
- tender in ________ groove
- pain with ____________
- inflammatory, degenerative
- microtrauma
- bicipital
- tensile loading
Biceps tendon rupture commonly occurs at _________ or upon exiting ________________.
- origin
- bicipital groove
What is the common presentation of a biceps tendon rupture?
- popeye deformity
- most commonly age >50
- Hx biceps tendinosis
ADHESIVE CAPSULITIS
ADHESIVE CAPSULITIS
What is adhesive capsulitis?
Extreme stiffness or immobility in the shoulder joint, usually following injury and caused by the adhesions in the joint and inflammation of the capsule of the humerus
Adhesive capsulitis affects _____ more and occurs in the 5th and 6th decades of life.
women
What are some risk factors for adhesive capsulitis?
- DM (5-6 times more likely)
- Prior history in either shoulder
- With adhesive capsulitis, __________ with disuse may be a potential complication.
- Normal progression is normal function will be regained ~ ______ following onset.
- osteopenia
- 2 years
What are the 4 stages of adhesive capsulitis?
- Stage I: Pre-adhesive
- Stage II: Freezing stage
- Stage III: Maturation
- Stage IV: Thawing
In stage I (__-__ months) adhesive capsulitis there is an early loss of ___ ROM with intact strength. Tissue starts to get hypervascular, hypertrophic synovitis and we see normal capsular tissue.
- 0-3 months
- ER
In stage II (__-__ months) adhesive capsulitis we see a __________ motion loss and loss of ______ fold. This is where we see ________, hypervascular synovitis described as having a Christmas tree appearance.
- 4-12 months
- multidirectional
- axillary
- thickened
In stage III (__-__ months) adhesive capsulitis we see significant ______________ A/PROM and pain at end-range and possibly at night. In this stage the tissue has ____ synovitis but progressive capsuloligamentous ___________ and we still see a loss of the ________ fold.
- 9-15 months
- multidirectional
- less
- fibrosis
- axillary
In stage IV (__-__ months) adhesive capsulitis we see ______ pain, gradual return in _____, but ________ may remain. The tissue _______ remains and we see a receding synovial involvement.
- 15-24 months
- minimal pain, gradual return in ROM, stiffness may remain
- fibrosis
What are some common medical interventions for adhesive capsulitis?
- NSAIDs, oral steroids
- Intra-articular steroid injections
- MUA (manipulation under anesthesia)
- Suprascapular nerve block
- Hydrodilation
- Arthroscopy
- Open release
MUA has an increased risk for what?
- fracture (humerus)
- subscapularis rupture
- labral tear
- biceps tendon injury
SHOULDER OA
SHOULDER OA
What is a symptom seen with OA at the GH joint?
anteriolateral shoulder pain
OA Glenohumeral Physical Exam Findings:
- ____-_________ A/PROM limitations
- audible/palpable _______
- shoulder weakness/________
- diminished joint mobility
- possible relief of pain with _______ mobilization
- multi-directional
- crepitus
- dyskinesia
- traction
Osteoarthropathy of the AC joint can have a possible concomitant _________ syndrome and/or __________ tendinopathy.
- impingement
- rotator cuff
What symptoms are seem with OA of the AC joint?
- pain local to AC joint
- painful with overhead activities/ reaching across trunk
OA AC Joint Physical Exam Findings:
- _____ tenderness ACJ line
- painful/limited shoulder AROM (________ and ___________)
- focal
- elevation and horizontal adduction
HYPERMOBILITY
HYPERMOBILITY
What are the 2 different ways to classify hypermobile shoulders?
- AMBRI = Atraumatic Multidirectional Bilateral for Rehabilitation and possibly Inferior capsular shift surgery
- TUBS= Traumatic Unilateral Bankart needing/ responding to Surgery
What are the 3 types of instabilities?
- Posterior
- Anterior
- Inferior
________ instability is rare, only accounting for <2% of shoulder dislocations.
Posterior
What are some common MOIs for posterior instability?
- seizure
- electric shock
- trauma
What symptoms are seen with posterior instability?
- symptoms of instability with shoulder in flexed/abducted position
- pain severe
How would a patient with a posterior instability present during a physical examination?
- limited/painful shoulder AROM (ER, elevation)
- observable prominence posterior shoulder
__________ instability is even more rare than posterior instability.
Inferior
What are some common MOIs for inferior instability?
carrying heavy objects by side
What symptoms are seen with inferior instability?
severe pain
How would a patient with inferior instability present during a physical examination?
- shoulder locked in abducted position
- sulcus observable
____________ instability is the most common direction of dislocation.
Anterior
What are common MOIs for anterior instability?
- Abduction
- ER
- Extension
What symptoms are seen with anterior instability?
feeling of shoulder mal-placement following acute event
How would a patient with anterior instability present during a physical examination?
- observed self-immobilization by patient (slightly abducted/externally rotated)
- spasm/guarding to stabilize the joint
- positive instability tests
- possible hypomobility of posterior GH capsule
- painful/limited AROM
- painful/limited/guarded PROM
What are some potential complication of an anterior dislocation?
- Neurovascular injury
- Hill-Sacks Lesion
- Bankart Lesion
- Subsequent dislocation risk increased
What is a Hill-Sacks Lesion?
Compression of the posterior humeral head secondary to impaction of glenoid.
What is a Bankart Lesion?
Tear on the lower rim of the labrum.
Do patients have an increased risk for more dislocations after their first? If so, what is the % by age?
Yes
- <20y/o = 70-85%
- 20-40 y/o = 50-70%
- > 40 y/o = 10-15%
Multi-directional instability is more of our _______ type instability. With this, the patient will report the ability to do what?
- AMBRI (general hypermobility)
- ability to sublux GH joint at will
What are some health conditions that can cause multi-directional instability?
- Ehlers-danlos syndrome
- Trisomy 21 (Downs Syndrome)
Repetitive stress can increase risk of degenerative changes to _________, _______ and other bony/soft tissue structures.
- rotator cuff
- joint surfaces
BANKART LESIONS AND SLAP LESIONS
BANKART LESIONS AND SLAP LESIONS
Bankart lesion is an avulsion injury of the ____________ labrum.
anterior inferior
With a Bankart lesion, there may or may not be a ________ injury.
capsular
How will a patient with a Bankart lesion present?
- clicking/clunking/popping/locking
- deep shoulder pain
- Hx trauma (dislocation), recurrent subluxations
What does SLAP lesion stand for?
Superior Labral lesion Anterior and Posterior
SLAP lesions are injuries where the _______ tendon inserts.
biceps
SLAP lesions can occur via _____trauma or a ______ trauma. They are commonly associated with _________ athletes.
- microtrauma or single trauma
- overhead
SLAP lesions are commonly concomitant with ____________ lesion (full/partial tear 40%).
rotator cuff lesion
How will a patient with a SLAP lesion present?
- aggravation with repetitive overhead activities
- Hx FOOSH/traction trauma
- GH IR ROM limitations
- muscle performance impairments
- locking/clicking/popping/catching with shoulder motion
- most often concomitant RC/intrarticular/biceps tendon/ ACJ injures
How many types of SLAP lesions are there?
4
Type I SLAP lesion
-Fraying and degeneration of the _________ labrum with a _______ biceps tendon anchor
- superior
- normal
Type II SLAP lesion
-Fraying of the superior labrum, but their hallmark is a pathologic detachment of the ______ and ________ anchor from the superior glenoid
labrum and biceps
Type III SLAP lesion
-Superior labrum has a _______ tear analogous to a bucket-handle tear in the meniscus of the knee. The remaining rim of labral tissue is well anchored to the glenoid, and the biceps anchor is _______.
- vertical
- intact
Type IV SLAP lesion
-Vertical tear of the superior labrum, but this superior labral tear extends to a variable extent up into the _______ tendon as well.
biceps
OVERHEAD THROWING ATHLETE
OVERHEAD THROWING ATHLETE
What is GIRD?
Glenohumeral Internal Rotation Deficit
What is the posture of an overhead throwing athlete?
- protracted
- anteriorly tilted scapula
(pec minor tightness and/or guarding, lower trap weakness)
- In regards to GIRD, pitchers exhibited excessive ____ and lacking ____.
- The humeral head of these pitchers on the throwing side was 17 deg increase in _______ when compared to the non-throwing arm.
- The throwing shoulder was stronger with ___ and _______, weaker with ___.
- ER, IR
- retroversion
- IR and Adduction, ER
