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S3- Musculoskeletal > Shoulder Common Clinical Presentations > Flashcards

Shoulder Common Clinical Presentations Flashcards

1
Q

FRACTURES

A

FRACTURES

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2
Q
  • Fractures of the proximal humerus make up __% of fractures in the appendicular skeleton.
  • They are commonly referred to as FOOSH, what is this?
A
  • 5%

- Fall on outstretched hand

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3
Q

What populations are at risk for fractures of the proximal humerus?

A
  • children (growth plate)

- older adults (osteopenic/osteoporotic bone)

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4
Q
  • 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?
A
  • When it is nondisplaced and stable

- When they have poor outcome or increased risk for complications (ORIF)

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5
Q

What are some risk factors that indicate a poor outcome of a proximal humerus fracture?

A
  • severe osteoporosis
  • smoking
  • drug and alcohol abuse
  • DM
  • RA
  • immunocompromise including steroid meds and concurrent neoplasm
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6
Q

What is Neer’s Classification?

A

A way to classify different proximal humerus fractures.

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7
Q

What neurovascular structures tend to be injured with proximal humerus fractures?

A
  • Circumflex humeral artery

- Axillary nerve

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8
Q
  • Fractures of the clavicle make up __-__% of all fractures in the appendicular skeleton.
  • They are commonly related to _______ injury/ direct ________.
A
  • 5-10%

- FOOSH injury/ direct trauma

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9
Q
  • 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?
A
  • Distal = 16.6%
  • Middle = 81.3%
  • Proximal = 2.1%
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10
Q

Why do we want to consider where a clavicle fracture has occured?

A
  • 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
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11
Q

How would a patient with a clavicle fracture present during a physical examination?

A
  • 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)
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12
Q

SC AND AC JOINT INJURIES

A

SC AND AC JOINT INJURIES

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13
Q

__% of shoulder girdle injuries happen at the SC joint. 80% of these are _____ or ____ related.

A
  • 3%

- sport or MVC

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14
Q

What is the mechanism of SC joint injuries?

A

Shoulder forced anteriorly or medially (blow to posterior shoulder)

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15
Q

SC Sprains most common:

  • Mild: ______ joint _______ ligament integrity compromise
  • Moderate: ________ joint with _________ ligament compromise
  • Severe: _______ joint with _________ ligament disruption
A
  • stable, without
  • subluxed, partial
  • unstable, complete
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16
Q

How would a SC joint injury present?

A
  • observable deformity
  • local tenderness
  • pain with shoulder motion (elevation especially)
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17
Q

__-__% of acute shoulder injuries are AC joint injuries. (up to 40% for athletes)

A

9-10%

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18
Q

What is the mechanism of AC joint injuries?

A

fall, sport or MVC related

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19
Q

What are the 2 ligaments that can be compromised during an AC joint injury? What kind of stability is compromised with each?

A
  • AC ligament- compromised horizontal stability

- CC ligament- compromised vertical stability

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20
Q

The classification system for AC joint injuries is based on the extend of ________ displacement.

A

clavicular

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21
Q

How would a AC joint injury present?

A
  • Shoulder weakness (AROM or resistive)
  • Local tenderness (+ AC joint palpation test)
  • Possible deformity
  • Possible swelling
  • Pain with shoulder movement
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22
Q

How many AC separation types are there?

A

6

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23
Q
  • Type I AC separation involves a sprain of the ___ ligament.
  • Type II AC separation involves rupture of the ___ ligaments and sprain of the ____ ligaments.
A
  • AC

- AC, CC

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24
Q

What does treatment of type I and II AC joint separations look like?

A
  • typically brief period of immobilization/sling use (1-2 weeks)
  • gentle ROM, isometric exercises
  • progression to scap stab exercises
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25
Q

Type III AC separation involves rupture of the ___ and ____ ligaments and detachment of the _______ and __________ muscles.

A
  • AC and CC

- deltoid and trapezuis

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26
Q

Type III AC separation can be treated ________ or _________.

A

surgically or conservatively

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27
Q

What does treatment of Type III AC joint separations look like?

A
  • 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
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28
Q
  • 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 ____________.
A
  • trapezius
  • III
  • biceps and coracobrachialis
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29
Q

Types IV, V, and VI are _________ managed and we see them _________.

A
  • surgically

- post-op

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30
Q

What does treatment of Type IV, V, and VI AC joint seperations look like?

A
  • progress toward full ROM, f/b strengthening exercises
  • manual therapy interventions as appropriate
  • scap stab/ proprioceptive training progress
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31
Q

SCAPULAR DYSKINESIA

A

SCAPULAR DYSKINESIA

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32
Q

What is scapular dyskinesia?

A

Abnormal mobility or function of the scapula.

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33
Q

What 3 things are present in scapular dyskinesia?

A
  • motion abnormalities
  • mechanical neck and shoulder pain
  • diminished soft tissue extensibility
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34
Q

What motion abnormalities are present in scapular dyskinesia?

A
  • diminished posterior tilting, upward rotation, and clavicle retraction
  • excessive clavicle elevation
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35
Q

Mechanical neck and shoulder pain comes from hyperactive _________. Also may come from impaired motor function of the _____________ as well as ____________.

A
  • upper trap

- lower and mid traps as well as serratus anterior

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36
Q

In scapular dyskinesia we see diminished soft tissue extensibility of what structures/muscles?

A
  • pec minor
  • posterior shoulder/capsule
  • levator scap, lats, GH external rotators
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37
Q

RCT INJURY

A

RCT INJURY

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38
Q

What can cause subacromial impingement?

A
  • Excessive superior translation of humeral head with elevation
  • Overuse of the shoulder causing microtrauma leading to inflammation
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39
Q

What structures can be impinged in subacromial impingement?

A
  • rotator cuff tendons
  • subacromial bursa
  • long head of biceps tendon
  • coracoacromial ligament
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40
Q

> __ years old is increased risk for rotator cuff tendinopathy.

A

40

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41
Q
  • 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?
A
  • calcification
  • females
  • hypoxia
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42
Q

What is tendonitis?

A

Tendon pain caused by inflammation.

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43
Q

What is tendinosis?

A

Microtrauma that results in degeneration or breakdown of a tendons collagen. (Chronic)

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44
Q

What are some abnormalities that can cause subacromial impingement?

A
  • 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)
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45
Q

What is the typical clinical progression of rotator cuff tendinopathy?

A
  • tendonitis
  • degenerative tendinosis
  • partial thickness tear
  • full thickness tear
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46
Q

What are the symptoms of rotator cuff tendinopathy?

A
  • dull ache lateral upper/lower arm
  • reaching away from body painful
  • over shoulder-level activities
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47
Q

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 _______________
A
  • 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
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48
Q
  • What is the glenohumeral painful arc?

- What is the acromioclavicular painful arc?

A
  • 60°-120°

- 170°-180°

49
Q

With rotator cuff tears, what 4 things do we want to consider?

A
  • size
  • location
  • direction
  • depth
50
Q

Does surgical or conservative intervention of partial/full tendon tears have better long-term outcomes?

A

They are comparable

51
Q

Rotator Cuff Tear Physical Exam Findings:

  • findings described for RC _____________
  • significant __________ with shoulder
  • compensation with __________ motion when attempting to elevate UE
A
  • tendinopathy
  • weakness
  • scapular
52
Q

After the age of 60 about __% are thought to have shoulder pathologies.

A

50%

53
Q

Risk For Rotator Cuff Injury in the Older Adult:

  • tissue changes with normal physiological ______
  • “_______ _______”
  • fatty infiltration of ___________ and ________ muscles
A
  • aging
  • “critical zone”
  • supraspinatus and infraspinatus
54
Q

What is rotator cuff critical zone?

A

Portion of supraspinatus that is now no longer vascular, not allowing repair.

55
Q

Older patients also present with ________ changes and may have ________ and ___________ impairements.

A
  • postural

- memory and cognitive

56
Q

BICEPS TENDON INJURY

A

BICEPS TENDON INJURY

57
Q

Biceps tendon lesion can be related to a _______ or a __________.

A

tendinosis or tendonitis

58
Q

Biceps tendon instability is associated with ______ lesion. It is also commonly associated with ______ tears and ______ lesions.

A
  • pulley lesions

- subscap tears and SLAP lesion

59
Q

Biceps Tendon Lesion Tendinopathy:

  • Initial __________ response f/b ________ process
  • mechanism= ___________
  • tender in ________ groove
  • pain with ____________
A
  • inflammatory, degenerative
  • microtrauma
  • bicipital
  • tensile loading
60
Q

Biceps tendon rupture commonly occurs at _________ or upon exiting ________________.

A
  • origin

- bicipital groove

61
Q

What is the common presentation of a biceps tendon rupture?

A
  • popeye deformity
  • most commonly age >50
  • Hx biceps tendinosis
62
Q

ADHESIVE CAPSULITIS

A

ADHESIVE CAPSULITIS

63
Q

What is adhesive capsulitis?

A

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

64
Q

Adhesive capsulitis affects _____ more and occurs in the 5th and 6th decades of life.

A

women

65
Q

What are some risk factors for adhesive capsulitis?

A
  • DM (5-6 times more likely)

- Prior history in either shoulder

66
Q
  • With adhesive capsulitis, __________ with disuse may be a potential complication.
  • Normal progression is normal function will be regained ~ ______ following onset.
A
  • osteopenia

- 2 years

67
Q

What are the 4 stages of adhesive capsulitis?

A
  • Stage I: Pre-adhesive
  • Stage II: Freezing stage
  • Stage III: Maturation
  • Stage IV: Thawing
68
Q

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.

A
  • 0-3 months

- ER

69
Q

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.

A
  • 4-12 months
  • multidirectional
  • axillary
  • thickened
70
Q

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.

A
  • 9-15 months
  • multidirectional
  • less
  • fibrosis
  • axillary
71
Q

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.

A
  • 15-24 months
  • minimal pain, gradual return in ROM, stiffness may remain
  • fibrosis
72
Q

What are some common medical interventions for adhesive capsulitis?

A
  • NSAIDs, oral steroids
  • Intra-articular steroid injections
  • MUA (manipulation under anesthesia)
  • Suprascapular nerve block
  • Hydrodilation
  • Arthroscopy
  • Open release
73
Q

MUA has an increased risk for what?

A
  • fracture (humerus)
  • subscapularis rupture
  • labral tear
  • biceps tendon injury
74
Q

SHOULDER OA

A

SHOULDER OA

75
Q

What is a symptom seen with OA at the GH joint?

A

anteriolateral shoulder pain

76
Q

OA Glenohumeral Physical Exam Findings:

  • ____-_________ A/PROM limitations
  • audible/palpable _______
  • shoulder weakness/________
  • diminished joint mobility
  • possible relief of pain with _______ mobilization
A
  • multi-directional
  • crepitus
  • dyskinesia
  • traction
77
Q

Osteoarthropathy of the AC joint can have a possible concomitant _________ syndrome and/or __________ tendinopathy.

A
  • impingement

- rotator cuff

78
Q

What symptoms are seem with OA of the AC joint?

A
  • pain local to AC joint

- painful with overhead activities/ reaching across trunk

79
Q

OA AC Joint Physical Exam Findings:

  • _____ tenderness ACJ line
  • painful/limited shoulder AROM (________ and ___________)
A
  • focal

- elevation and horizontal adduction

80
Q

HYPERMOBILITY

A

HYPERMOBILITY

81
Q

What are the 2 different ways to classify hypermobile shoulders?

A
  • AMBRI = Atraumatic Multidirectional Bilateral for Rehabilitation and possibly Inferior capsular shift surgery
  • TUBS= Traumatic Unilateral Bankart needing/ responding to Surgery
82
Q

What are the 3 types of instabilities?

A
  • Posterior
  • Anterior
  • Inferior
83
Q

________ instability is rare, only accounting for <2% of shoulder dislocations.

A

Posterior

84
Q

What are some common MOIs for posterior instability?

A
  • seizure
  • electric shock
  • trauma
85
Q

What symptoms are seen with posterior instability?

A
  • symptoms of instability with shoulder in flexed/abducted position
  • pain severe
86
Q

How would a patient with a posterior instability present during a physical examination?

A
  • limited/painful shoulder AROM (ER, elevation)

- observable prominence posterior shoulder

87
Q

__________ instability is even more rare than posterior instability.

A

Inferior

88
Q

What are some common MOIs for inferior instability?

A

carrying heavy objects by side

89
Q

What symptoms are seen with inferior instability?

A

severe pain

90
Q

How would a patient with inferior instability present during a physical examination?

A
  • shoulder locked in abducted position

- sulcus observable

91
Q

____________ instability is the most common direction of dislocation.

A

Anterior

92
Q

What are common MOIs for anterior instability?

A
  • Abduction
  • ER
  • Extension
93
Q

What symptoms are seen with anterior instability?

A

feeling of shoulder mal-placement following acute event

94
Q

How would a patient with anterior instability present during a physical examination?

A
  • 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
95
Q

What are some potential complication of an anterior dislocation?

A
  • Neurovascular injury
  • Hill-Sacks Lesion
  • Bankart Lesion
  • Subsequent dislocation risk increased
96
Q

What is a Hill-Sacks Lesion?

A

Compression of the posterior humeral head secondary to impaction of glenoid.

97
Q

What is a Bankart Lesion?

A

Tear on the lower rim of the labrum.

98
Q

Do patients have an increased risk for more dislocations after their first? If so, what is the % by age?

A

Yes

  • <20y/o = 70-85%
  • 20-40 y/o = 50-70%
  • > 40 y/o = 10-15%
99
Q

Multi-directional instability is more of our _______ type instability. With this, the patient will report the ability to do what?

A
  • AMBRI (general hypermobility)

- ability to sublux GH joint at will

100
Q

What are some health conditions that can cause multi-directional instability?

A
  • Ehlers-danlos syndrome

- Trisomy 21 (Downs Syndrome)

101
Q

Repetitive stress can increase risk of degenerative changes to _________, _______ and other bony/soft tissue structures.

A
  • rotator cuff

- joint surfaces

102
Q

BANKART LESIONS AND SLAP LESIONS

A

BANKART LESIONS AND SLAP LESIONS

103
Q

Bankart lesion is an avulsion injury of the ____________ labrum.

A

anterior inferior

104
Q

With a Bankart lesion, there may or may not be a ________ injury.

A

capsular

105
Q

How will a patient with a Bankart lesion present?

A
  • clicking/clunking/popping/locking
  • deep shoulder pain
  • Hx trauma (dislocation), recurrent subluxations
106
Q

What does SLAP lesion stand for?

A

Superior Labral lesion Anterior and Posterior

107
Q

SLAP lesions are injuries where the _______ tendon inserts.

A

biceps

108
Q

SLAP lesions can occur via _____trauma or a ______ trauma. They are commonly associated with _________ athletes.

A
  • microtrauma or single trauma

- overhead

109
Q

SLAP lesions are commonly concomitant with ____________ lesion (full/partial tear 40%).

A

rotator cuff lesion

110
Q

How will a patient with a SLAP lesion present?

A
  • 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
111
Q

How many types of SLAP lesions are there?

A

4

112
Q

Type I SLAP lesion

-Fraying and degeneration of the _________ labrum with a _______ biceps tendon anchor

A
  • superior

- normal

113
Q

Type II SLAP lesion
-Fraying of the superior labrum, but their hallmark is a pathologic detachment of the ______ and ________ anchor from the superior glenoid

A

labrum and biceps

114
Q

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 _______.

A
  • vertical

- intact

115
Q

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.

A

biceps

116
Q

OVERHEAD THROWING ATHLETE

A

OVERHEAD THROWING ATHLETE

117
Q

What is GIRD?

A

Glenohumeral Internal Rotation Deficit

118
Q

What is the posture of an overhead throwing athlete?

A
  • protracted
  • anteriorly tilted scapula

(pec minor tightness and/or guarding, lower trap weakness)

119
Q
  • 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 ___.
A
  • ER, IR
  • retroversion
  • IR and Adduction, ER

S3- Musculoskeletal (27 decks)

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