SHOULDER COMPAINTS--WEEK 11 QUIZ Flashcards by ROGER ALONSO

Shoulder Complaints——Major categories X 8

1———–Impingement:
A- ____________- supraspinatus mm, subacromial bursa

B- ____________–: subscapularis mm

C- ___________–: posterior labrum, infraspinatus,
teres minor

Anterolateral:

Anteromedial

Posterolateral

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Shoulder Complaints——Major categories X 8

2–Instability
EX–traumatic or nontraumatic

3–Tendinitis/bursitis

4–DJD

5–Adhesive capsulitis

6–AC separation/GH dislocation

7–Fracture

8–Referred pain

KNOW

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History

1--Complaint: 
---------Pain, weakness, instability, tingling, etc.
2---Location: 
----------Anterior, posterior, lateral, superior
3--Traumatic vs. \_\_\_\_\_\_\_\_
4--\_\_\_\_\_\_\_\_\_\_\_ symptoms
5--Prior injuries
-----------Did they complete rehab?

overuse

Positional

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HISTORY = Specific questions X 7

1— Was there TRAUMA!!???

A–Fall on outstretched arm?
EX—-__________ fx; posterior dislocation; biceps, suprapinatus, or labral tear

B–Land on top of shoulder?
EX—-____ separation, distal clavicle Fx

C–Arm abducted & extended at impact?
EX—–ANTERIOR dislocation

D–GH locks & “clicks” back in place?
EX—-_________ ________

Clavicle

Labral tear

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HISTORY = Specific questions X 7

2–Specific Questions—Do you perform repetitive activities?

A–General: capsule sprain, muscle strain, tendinitis

B–Overhead positions?

–___________ syndrome
–Biceps, supraspinatus, bursa

C–Worse with lifting weights and/or HEAVY objects?
—Osteolysis of the ________ clavicle, labral tear

Impingement

distal

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HISTORY = Specific questions X 7

3—Specific Questions– Is there associated NECK pain?

A–Cervical spondylosis, disc lesion, facet
B–Trauma?
–Cervical sprain/strain, burner, ______ _______ injury
C–Is the neck & shoulder pain timing similar?
–Osteoarthritis (DJD), myofascial pain syndrome (MFPS)

brachial plexus

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HISTORY = Specific questions X 7

Specific Questions—4) Complaint of MORE stiffness than pain?

A--Past history of trauma?
---Unreduced GH dislocation
B---Did the stiffness get worse after a few weeks of pain in shoulder?
 = \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_
C--Arthritides?

Adhesive capsulitis

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HISTORY = Specific questions X 7

Specific Questions—5) Sense of ________ or instability?

Past history of trauma?
 = GH Dislocation
1) Labral tear
2) Tendon 
3) Muscle
4) Capsule tear/rupture

weakness

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HISTORY = Specific questions X 7

Specific Questions—6) _________ pain in other joints?

A--Rheumatoid arthritis
B--Ankylosing spondylitis
C--Pseudogout:
1) Calcium pyrophosphate deposition disease
2) Hydroxyapatite deposition disease
D--Degenerative joint disease

Concurrent

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HISTORY = Specific questions X 7

Specific Questions—7) Visceral complaints same time as the shoulder complaint?

A-GI complaints?
 = Referred pain from \_\_\_\_\_\_\_\_\_\_
B--Pulmonary complaints?
 = Infection, tumor, etc. (“No, House, there’s no fever and the white count is normal . . .”)
C--Cardiac complaints
 =  Myocardial infarction

gallbladder

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Location: Anterior

1) Traumatic
Fracture, GH dislocation, subacromial bursitis, capsular sprain, strain/rupture of the ____ _______ of biceps, labral tear

2) Non-traumatic or overuse
__________ syndrome, subcoracoid impingment, biceps tendinitis, subacromial bursitis, subscapularis tendinitis, subluxation

long head

Impingement

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Location: Lateral

1) Traumatic
Contusion, __________ sprain/rupture

2) Non-traumatic or overuse
Impingement syndrome, deltoid strain, suprapinatus strain/rupture, visceral referral

suprapinatus

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Location: Superior

1) Traumatic
___ separation, distal clavicle fracture

2) Non-traumatic or overuse
= Osteoarthritis (DJD) affecting the AC joint, osteolysis of the _______ clavicle

distal

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Location: Posterior

1) Traumatic
__________ fracture, posterior dislocation

2) Non-traumatic or overuse
Posterior impingement, infraspinatus/teres minor mm strain/tendinitis, posterior ______/________ mm strain

Scapular

deltoid/triceps

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Examination—1) Palpation

A--Superficial to deep
B--Tenderness of what?
------Be \_\_\_\_\_\_\_, it will often pinpoint the diagnosis
C--Edema
D--Deformity
E--Laxity

Examination—2) Range of motion

A) Trauma and pain in ALL ranges
— = ___________/fracture/rupture
B) Pain at MIDRANGE of abduction (70 -110°)
— = ___________ _________
C) Restriction of ACTIVE ROM only:
—_________/___________(duh)
D) Restriction of active & PASSIVE ROM:
— = ___________/__________
E) Inability to HOLD/LOWER the abducted arm:
— =____________ __________

specific

Dislocation

Impingement syndrome

Muscle/tendon

Capsule, bone

Rotator cuff

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Examination—3) Instability tests

A) DO NOT PERFORM on the ACUTE patient
B) Many patients are normally lax
C) Tests:
1) Crank test
2) Load and shift test
3) Apprehension test(s) 
***NOTE: When combined, found to be as sensitive as MRI for \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_***

labral tears

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Impingement

1---\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
A---Suprapinatus tendon
---Empty can (“Jobe’s”)
B--Biceps tendon
---Speed’s
C--Subacromial bursa
---“Push button” test

2---\_\_\_\_\_\_\_\_ -\_\_\_\_\_\_\_\_\_
A---Posterior labrum
---Infraspinatus mm
(Resisted external rotation with the arm at the side)
---Teres minor mm

Acromial arch

Posterior impingement

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Diagnoses—1) AC separation/sprain

A—Sudden pain from fall on outstretched arm or fall on TOP of shoulder, lifting heavy objects
B—_______/__________ deformity
C—Grade 1 & 2: = conservative care
1= SOME TEARING, no instability,
2= RUPTURE of AC lig, unstable
3= rupture of AC AND coracoclavicular ligs
(conoid and trapezoid), = __________
D—Grade 3: conservative care with Kenny Howard sling (2-3 weeks) then rehab (if not recovered, then send for surgical consult)

Palpable/visible

unstable

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Diagnoses—2) Adhesive Capsulitis

A—Usually over 40 y.o.
B—Females > Males
C—History of pain lasting for WEEKS (may or may not have a history of trauma) followed by gradual ________ of the shoulder as the pain diminishes
D—May be _________ in nature
E—Pain in active and passive ROM, especially _________ _______ AND ___________
F–Cervical spondylosis, hypothyroidism, and diabetes are related conditions
G–Patients note a dramatic DECREASE in shoulder ROM
I—In many cases, there is spontaneous resolution after 1-3 years (motion is RE-GAINED)

stiffening

autoimmune

external rotation and abduction

Diagnoses—3) Osteoarthritis

A–Should be considered in ALL _______ or __________ patients
B–Insidious onset of achy pain and loss of ROM
C—Loss of active and passive ROM

elderly

postraumatic

Diagnoses—4) Traumatic Instability

A—Pain or weakness with ___________ activity or in apprehension position
B—History of shoulder _____________
—-Potential damage to capsule, labrum, ligaments, tendons, humerus
C—ACUTE
—-Stabilize, passive care to decrease pain
D—CHRONIC
—-Evaluate for stability, begin rehab (surgical consult if treatment ineffective or condition not resolving)

overhead

dislocation

Dislocations

A—MALES > Females
B—YOUNGER (teens, early twenties)
C—The younger the age for the FIRST dislocation the GREATER the risk of ___________
D—The labrum, rotator cuff, and capsule can ALL be involved to varying degrees

re-dislocating

Care and/or treatment of DISLOCATIONS

A–Shoulder sling
—If over 30 → ONE week
—If under 30 → THREE weeks of immobilization
B–________ dislocators will require LESS time
C–Rehab may take up to ____ months

Chronic

T.U.B.S. (“Torn Loose”)

T–raumatic
U–nidirectional
B–ankart Lesion
S–urgery should be considered

Bankart Lesions

CLASSIC BANKART LESION (80%) - Labral avulsion from the ______ ______ with capsular stripping from the scapular neck.

BONY BANKART LESION (3%) Labral avulsion WITH BONE from the anterior glenoid rim and capsular stripping from the medial scapular neck.

glenoid rim

Chronic Labral Tears A---Pain and _________ with rotational movements, but ROM is usually full B---History of trauma or instability or laxity

clicking

A.M.B.R.I. ``` A--traumatic M--ultidirectional Instability B--ilateral Laxity R--ehabilitation Helps I--nferior Capsule Tightened ``` Surgical tightening of rotator interval The rotator interval is a triangular portion of the shoulder capsule which lies between the ________&_________ tendons

supraspinatus and subscapularis

These are difficult to tell apart & may occur together Impingement Tendinitis Bursitis Rotator cuff “tear” (strain)

KNOW

Impingement Syndrome 1---Shoulder pain that is worse with overhead activities, Hx of overuse. 2---Site of tenderness depends on structure being impinged - -Anterior: - ___________ bursa - -Humeral tuberosity: = __________ - -Posterior: = ________/__________ 3---Painful arc, Hawkins-Kennedy, Supraspinatus test, Impingement sign

subacromial supraspinatus teres minor/infraspinatus

Rotator Cuff Tear 1--History of chronic or acute trauma Overhead lifting, fall on an outstretched arm, arm twisted, etc… ---Chronic degeneration, overuse 2--Complain of pain with OVERHEAD activities or unable to RAISE THE ARM 3--__________: Most commonly torn tendon 4--Signs like impingement, may have weakness

Supraspinatus

Etiology of ROTATOR CUFF TEAR 75% of the time: Secondary to __________ 10% of the time: Acute injury 15% of the time: Secondary to instability/laxity

impingement

Radiographs OF ROTATOR CUFF TEAR Early stages show some _____ ________, but otherwise normal Late stages look similar to ________ ________ and DJD will often result from the damage that has occurred

mild sclerosis degenerative arthritis

Biceps tendon tear ``` 1---Bunching up of the muscle 2---(+) Transverse humeral ligament test 3---Testing reveals: ---Weak and painful = ________ tear ---Weak and painless = _______ tear (with or without neurologic damage) 4---Approx 50% of all ruptures occur thru the tendon of the ______ _________ ---Some strength will remain (short head remains intact) ```

partial full long head

Proximal Biceps Tendon Rupture (Long Head) 1--From resisted forced flexion (eccentric) 2---May be secondary to repetitive ______ ________ 3---Discoloration 4---Palpable and visible defect with “_________” muscle 5---Weakness on ___________ (Yergason’s) 6---Surgery for young; conservative care for elderly

cortisone injections popeye supination

“SLAP” Lesion 1--Superior Labrum, Anterior-to-Posterior 2--Detachment lesion of the superior aspect of the glenoid labrum, which serves as the __________ of the long head of the biceps C--A ________ injury, such as catching oneself falling, is a common cause D--A fall on the outstretched hand (“F.O.O.S.H.”), or repetitive activities (_______) may predispose to this injury

insertion traction pitching

“SLAP” Lesion (cont.) Type I: _______ and degeneration of the superior labrum (with firm attachment to the glenoid), normal biceps; usually degenerative in nature Type II: Detachment of _________ labrum and biceps insertion from the supra-glenoid tubercle (this is the MOST common type of SLAP lesion; may resemble a normal variant) Type III: “_______ ______-________” tear (biceps anchor is intact) Type IV: Vertical tear of the superior labrum, which extends into ______; may be treated w/ biceps tenodesis if more than 50% of the tendon is involved

Fraying superior Bucket handle-type biceps

Tendinitis & Bursitis 1---Usually _______ pain that is WORSE with most ROM (insidious, related to overuse, or result of a trauma) 2---_________ location of palpatory tenderness 3---Treat as any other tendinitis/bursitis 4---SLING for support, but do NOT leave it on for extended periods of time, and encourage shoulder exercises to tolerance

severe Distinct

Subacromial Bursa 1---A large synovial membrane which is adherent to ______________ of coracoacromial ligament, acromion, & deltoid laterally. (floor is adherent to rotator cuff & __________tuberosity) 2---Envelops proximal humerus. (facilitates GLIDING of proximal humerus UNDER coracoacromial arch)

undersurface greater

Calcific Tendinitis --1 1---Usually NOT seen until the _____ decade 2---________ patients are more likely to develop asymptomatic rotator cuff calcium deposits ---> ____% of insulin-dependent diabetics had tendon calcification (

4TH Diabetic 30%

Calcific Tendinitis --2 3--In most cases, clinical symptoms will resolve spontaneously in __-___ days. (where as the DEPOSIT may persist on radiographs) ---Treat as for all tendinitis

7-10

Osteolysis of the Clavicle 1---Diffuse pain felt at the _________ clavicle 2---Patient is often a young, serious weightlifter. --- (as opposed to an old, casual weightlifter?) 3---Complaints of pain with bench pressing, overhead pressing, and/or dips. 4--Cause unknown--- (usually related to ____ trauma resulting in resorption of the distal clavicle) 5---Pain with ____ >90, ortho exam is often unremarkable 6---AC spot view --- (WIDENING of joint space, subchondral defects) 7--Ergonomically modify to NARROW grip, avoid dips 8---Surgery= acromioplasty

distal AC ABD

Management OF OSTEOLYSIS --Conservative care for up to 6 months --Palliative care for symptoms --_________ exercises --Broomstick exercises --Wall crawl --Body blade --Tubing (followed by more challenging strength exercises)

Pendulum

Little Leaguer’s Shoulder 1--Proximal humerus pain in an adolescent that occurs primarily with ________ _________ 2--Salter Harris Type __ (due to ROTATIONAL stress on the growth plate) 3--Palpable tenderness 4--Pain on resisted EXTERNAL rotation and supraspinatous test 5--Diagnosed by x-ray—WIDENED humeral physis (comparison to non-painful side) 6--Switch to interval training

throwing hard 1

Nerve Entrapments Near the Shoulder 1---__________ nerve Sensory: Supraspinatous area (Spinal nerve root?) SUPRAspinatus/INFRAspinatous mm atrophy Secondary to suprascapular notch trauma 2---__________ (circumflex) nerve Sensory: Lateral DELTOID area (Spinal nerve root?) Deltoid/teres minor mm atrophy Secondary to anterior humeral dislocation 3---________ nerve Sensory: DORSAL surface of hand (Spinal nerve root(s)?) Elbow/wrist extensor mm atrophy Secondary to humerus fracture

Suprascapular Axillary Radial

Nerve Entrapments 4---_____________ N Sensory: Lateral forearm (Spinal nerve root?) Elbow flexor mm atrophy (BICEPS) Secondary to forced elbow hyperextension or repetitive pronation 5---_______ ________ SERRATUS ANTERIOR mm atrophy (“scapular winging”) backpack 6---___________ __________ N Trapezius mm atrophy backpack

Musculocutaneous Long Thoracic Spinal Accessory

Fractures 1---Clavicle- usually MIDDLE third 2---Scapula 3---Humerus ---______ fracture: occurs in the great tubercle secondary to relocation of an anterior dislocation

Flap

Myositis Ossificans 1----___________ bone formation secondary to trauma to sheath covering muscle or bone Refer if: ``` 1--__________ is discovered 2--Ligament/tendon rupture is suspected instability that would likely result in permanent disability 3--Non-reduced dislocation 4--Infection 5--Tumor ```

Heterotopic ***Heterotopic ossification--- is the name used to describe the formation of bone in abnormal locations. Usually forming in soft tissues of the body, Fracture