Shoulder Common Clinical Presentations Flashcards
List several common clinical presentations of the shoulder complex
- fracture or other bony abnormality
- AC or SC Joint dysfunction
- Scapular dyskinesia
- Rotator cuff lesion
- subacromial pain syndrome
- adhesive capsulitis
- GH instability
- Glenoid labrum lesion
- including SLAP lesions
- Osteoarthropathy
- Biceps tendon lesion
list possible locations for fractures at the shoulder complex
- proximal humerus (~5% in appendicular skeleton)
- clavical (5-10% of all fractures)
- most common in middle 3rd of clavicle
- can damage subclavian artery and brachial plexus
what is FOOSH?
Fall On Outstretched Hand
injury that commonly causes proximal humeral fractures
T/F: fractures of the proximal humerus respond better to surgical interventions and have better outcomes
FALSE
better outcomes with conservative management
with a proximal humeral fracture, what neurovascular structures are commonly injuried?
- Axillary nerve
- circumflex humeral artery
be sure to check sensation/function of axillary nerve and deltoid following a fracture
describe the most common mechanism of injury for SC joint injuries
shoulder forced anteriorly or medially (blow to the posterior shoulder)
very rare injuries
almost always there is a high traumatic force applied
what type of SC joint injury is the most common?
sprains (graded as mild, moderate, or severe depending on ligament damage)
dislocations account for 3% of shoulder girdle dislocations
describe the common clinical presentation of an SC joint injury
- observable deformity
- local tenderness
- pain w/shoulder motion
what is the most common mechanism of injury for AC joint injuries?
fall, sport or MVC related
how are AC joint injuries classified?
by the extent of clavicular displacement
6 types
describe typical physical examination findings with an AC Joint Injury
- weakness and pain w/shoulder motion (AROM or resistive testing)
- local tenderness (+ AC Joint palpation test)
- possible observable deformity
- possible swelling
how are AC joint injuries (types I and II) typically managed?
conservatively
- brief period of immobilization/sling use ~1-2 weeks
- gentle ROM, isometric exercises
- progression to scapular stabilization exercises
how are type III AC Joint injuries typcially managed?
surgery or conservatively
- sling immobilization followed by progression to PROM
- full PROM 2-3 weeks after immobilization
- progressive shoulder strengthening
- RTS 6-12 weeks
- reconstruction if limitations persists >/= 3 months
how are types IV, V and VI AC joint injuries managed?
surgically
- post-op management includes:
- progressing toward full ROM, f/b strengthening progression
- manual therapy interventions as appropriate
- scap stab/proprioceptive training progression
what is scapular dyskinesia?
characterized by poor coordination of shoulder musculature which can result in stress/strain on other structures
motion abnormalities, mechanical neck and shoulder pain along with diminished soft tissue extensibility observed
what types of motion abnormalities will be observed with scapular dyskinesia?
diminished posterior tilting, upward rotation, and clavicle retraction
excessive clavicle elevation
what can cause mechanical neck and shoulder pain in scapular dyskinesia?
- hyperactive upper trap
- impaired motor performance
- lower and mid traps
- SA
where would you expect to see diminished soft tissue extensibility in scapular dyskinesia?
- pec minor
- posterior shoulder/capsule
- levator scap
- latissimus dorsi
- GH external rotators
what can cause a biceps tendon lesion?
- instability
- associated with a pulley lesion
- sub scap tears
- SLAP lesions
- tendinopathy
- initial inflammatory response f/b degenerative process.
- pain w/tensile loading
- ruptures
- commonly occur at origin or upon exit of biciptial groove
- Popeye deformity
what types of things can cause a rotator cuff lesion?
- tendinopathy due to subacromial impingement
- tendinosis due to microtrauma
- partial/full tears
what is a subacromial impingement?
excessive superior translation of humeral head w/elevation
risks:
- > 40 yrs old
- calcific tendonitis
- females > males
- possible hypoxic mechanism
what types of abnormalites can lead to subacromial impingement and thus a tendinopathy?
- tissue abnormalities
- anatomic abnormalities of acromion
- bursitis
- calcific bone spur
- tendon thickening
- Other
- altered scapulothoracic/scapulohumeral kinematics
- postural abnormalities
- superior translation of humeral head during elevation
- decreased GH stability
- “tight” posterior capsule
describe the typical clincial progression and symptoms of a rotator cuff tendinopathy
- Progression
- tendonitis → degenerative tendinopathy → partial thickness tear → full thickness tear
- Symptoms
- dull ache lateral upper/lower arm
- reaching away from body painful
- over shoulder-level activities painful
with a rotator cuff tendinopathy, what types of things are found during a physical exam?
- common pain in lateral proximal upper arm
- possibly painful arc
- weakness/pain w/AROM, MMT, passive stretching of involved contracile units
- tender at insertion site
- muscle guarding peri-scapular musculature
- altered scapular kinematics
- diminished posterior tilting, upward rotation, excessive IR
- pec minor tightness
- decreased posterior capsule length
- impaired SA and lower trap
when is pain felt during a “painful arc”?
~60-120 degress of elevation
if they only have pain at end range might be AC joint dysfunction
how are rotator cuff tears described?
- size
- location
- direction
- depth
T/F: there are no differences in long term outcomes between conservative and surgical management of a rotator cuff tear?
TRUE
what makes an older adult have a greater risk for rotator cuff tendinopathies?
- postural changes
- tissue changes
- fatty infiltration of supraspinatus and infraspinatus
- memory and cognitive impairments/neurodegenerative disease make it harder to recall precautions
list risk factors for adhesive capsulitis
- women > men
- 5th and 6th decade of life
- DM (5-6x more likely)
- prior history in either shoulder
the pathology of adhesive capsulitis is broken down into ____ stages
4 stages
natural progression → normal function regained 2 years following onset
describe stage 1 of adhesive capsulitis
pre-adhesive (0-3 months)
- early loss of ER ROM w/intact strength
- hypervascular, hypertrophic synovitis; and normal capsular tissue
describe stage II of adhesive capsulitis
Freezing stage (4-12 months)
- multidirectional motion loss
- thickened, hypervascular synovitis described as having a christmas tree apperance
- loss of axillary fold
- can result in risk of impingement/irritation during elevation
describe stage III of adhesive capsulitis
Maturation (9-15 months)
- symptoms
- pain at end range and possibly at night
- significant multi-directional A/PROM limitations
- tissue: less synovitis, progressive capsuloligamentous fibrosis
- loss of axillary fold
describe stage IV of adhesive capsulitis
Thawing (15-24 montsh)
- symptoms
- minimal pain
- gradual return in ROM
- stiffness may remain
- tissue: fibrosis remains, receding synovial involvement
what type of medical interventions are there for adhesive capsulitis?
- pharmacologic: NSAIDs, oral steroids
- Intra-articular steroid injections
- MUA (manipulation under anesthesia)
- Suprascapular nerve block
- hydrodilation (Brisement)
- Surgery
- arthroscopy
- open release
what are symptoms of oseoarthropathy at the GH joint?
anteriolateral shoulder pain
describe typical physical exam findings for osteoarthropathy of the GH joint
- multi-directional A/PROM limitations
- pain/firm or bony end-feel
- audible/palpable crepitus
- shoulder weakness/dyskinesia
- diminished joint mobility
- possible relief of pain w/joint traction
what are symptoms of osteoarthropathy of the AC joint?
- pain local to area of ACJ
- painful with OH activities/reaching across trunk
list various ways a shoulder can be hypermobile
- posterior instability
- anterior instability
- inferior instability
- SLAP (superior labrum anterior posterior) lesion
- multi-directionally
what are the 2 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
In what direction is shoulder instability most common?
Anterior
Common MOI → abduction/ER/extension
describe common MOI, symptoms, and physical exam findings for posterior instability at the shoulder
- common MOI → seizure, electrical shock, trauma (diving pool, MVA)
- symptoms
- severe pain
- instability symptoms when shoulder is flexed/abd position (pushing door open)
- Physical Exam
- limited/painful shoulder AROM (ER, elevation)
- observable prominence posterior shoulder
describe common MOI, symptoms, and physical exam findings in inferior instability at the shoulder
- common MOI → carrying heavy objects by side
- symptoms
- severe pain
- Physical exam
- shoulder locked in abducted position
- sulcus observable
*more rare type of instability
describe the symptoms and physical exam findings of anterior instability at the shoulder
- symptpms
- feeling of shoulder mal-placement following acute event
- physical exam
- observed self-immobilization by pt (slightly ABD/ER)
- positive instability tests
- possible hypomobility of posterior GH capsule
- painful/limited AROM
- painful/limited/guarded PROM
list several potential complications to anterior dislocation of the GH joint
- neurovascular injury
- Hills-Sacks Lesion
- Bankart Lesion
- increased risk of subsequent dislocation
- increases even more if it occured when you’re young
what is a Hills-Sack Lesion?
compression of the posterior humeral head secondary to impaction of glenoid
what is a Bankart Lesion?
an avulsion injury of anterior inferior labrum
presenting with:
- clicking/clunking/popping/locking
- deep shoulder pain
- Hx trauma (dislocation), recurrent subluxations
what is multi-directional instability at the GH joint?
can be benign hypermobility or related to other health care conditions (Ehlers-Danlos, Trisomy 21)
pt may report ability to sublux GH joint at will
what is a SLAP lesion?
Superior Labral lesion that are both Anterior and Posterior
mechanism → microtrauma or single trauma
describe the presentation of a SLAP lesion
- aggravation w/repetitive OH activities
- Hx FOOSH/traction trauma
- GH IR ROM limitations
- muscle performance impairments
- scapulothoracic
- scapulohumeral
- rotator cuff
- lockin/clicking/popping/catching with shoulder motions
- most often concomitant rotator cuff/intra-articular/biceps tendon/ACJ injuries
how many types of SLAP lesions are there and how are they classified?
4 types
classified by location of fraying/degeneration
describe a type I SLAP lesion
fraying and degeneration of the superior labrum with a normal biceps tendon anchor
describe a type II SLAP lesion
fraying of the superior labrum
hallmark is the pathologic detachment of the labrum and biceps anchor from the superior glenoid
describe a type III SLAP lesion
superior labrum ha a vertical tear analogous to a bucket handle tear in the meniscus of the knee
the remaining rim of the labral tissue is well anchored to the glenoid, and the biceps anchor is intact
describe a type IV SLAP lesion
vertical tear of the superior labrum, but this superior labral tear extends to a variable extent up into the biceps tendon as well
what is GIRD?
Glenohumeral Internal Rotation Deficit
common in OH athletes
greater motion with ER, limited IR
throwing shoulder stronger with IR and ADD, weaker with ER
posterior muscle tightness vs guarding
