Shoulder Complex Common Clinical Presentations Flashcards
Fractures of the proximal humerus are often caused by what two things?
- FOOSH (Fall on out-stretched hand)
2. Direct trauma to the areas
Those who are at increased risk of Fracturing the proximal humerus are what two groups?
- Children (growth plate)
2. Older adults (osteopenic/ osteoporotic bone)
Conservative treatment of Fractures of the proximal humerus includes what methods?
nondisplaced & stable (no surgery)
Surgical outcomes of Fractures of the proximal humerus are poor/increased risk for complications when patient has what factors?
- Hx smoking
- DM
- RA
- Neoplasms
- Severe osteoporosis
What is ORIF for Fractures of the proximal humerus?
Open Reduction Internal Fixation - Incision made to get to fraction site and hardware is placed to stabilize
Neurovascular structures possible involved with fractures of the proximal humerus?
- Circumflex Humeral Artery
2. Axillary Nerve (check function of lateral arm sensory and deltoid function)
Clavicle fractures account for what % of all fractures?
5-10%
Clavicle fractures are commonly related to what 2 types of injuries?
- FOOSH
2. Direct Trauma
What potential secondary vascular/neurologic injuries to clavicle fractures?
- Brachial plexus passes deep to middle clavicle
When a clavicle fracture heals out of alignment, what is the possible outcome?
angled downward might impinge on neurovascular structures
What 4 things are you looking for in a physical examination for a clavicle fracture?
- Guarded shoulder motion
- Supporting UE with contralateral UE
- Deformity (palpate bulge)
- Extreme tenderness
What 2 signs should you check that are consistent with secondary brachial plexus injury due to clavicle fracture? What should you not test?
- Radial pulse
- Neuro testing (sensation)
Do not test myotome -> can worsen injury
80% of SC joint injuries are found in what 2 types of injuries?
- Sport
2. MVC
Describe the difference in joint stability (subluxed, unstable, stable) and ligament integrity (complete disruption, none, partial) for SC joint sprains:
Mild -
Moderate -
Severe -
- Mild: stable joint without ligament integrity compromise
- Moderate: subluxed joint with partial ligament compromise
- Severe: unstable joint with complete ligament disruption
A patient with SC joint injury will present with what 4 things?
- Hx
- Observable deformity
- Local tenderness
- Pain with shoulder motion
What are 3 possible mechanisms for AC joint injury?
- Fall
- Spot
- MVC
If the AC is damaged in an ac joint injury, what motion will this compromise?
compromised horizontal stability
If the CC is damaged in an ac joint injury, what motion will this compromise?
compromised vertical stability
In the physical exam of an AC joint injury, what 5 things are you looking for?
- Weakness with shoulder (AROM/MMT)
- Local Tenderness (+ AC Joint Palpation Test)
- Possible observable deformity
- Possible Swelling
- Pain with shoulder motion
The most common type 1 separation of an AC joint injury includes injury to what ligament with what type of joint instability?
- AC lig sprain
2. No joint instability
Type 2 separation of an AC joint injury includes injury to what ligament with what type of joint instability?
- Ruptured AC ligament and Sprained CC lig
2. Clavicle unstable
For a Type 1/2 separation of an AC joint injury,
How long is the patient immobilized?
What exercises do you begin with?
What exercises do you progress to?
- Typically brief period of immobilization/ sling use (1-2 weeks)
- Gentle ROM (PROM->AROM), isometric exercises
- Progression to scap stab exercises
Type 3 separation of an AC joint injury includes injury to what ligament/muscles with what type of joint instability?
- Rupture of AC and CC lig and detached deltoid and trap muscle
- Clavicle unstable in vertical and horizontal planes
For a type 3 separation of an AC joint injury, describe difference between surgery vs. conservative method.
- Immobilized
- Progress to PROM 2-3 weeks after
- Progress to shoulder strengthening
If limitations of type 3 separation of an AC joint injury persist for >/= 3 months, what should occur?
reconstruction
Type 4 separation of an AC joint injury includes injury to what ligament/muscles?
Rupture of all supporting structures and clavicle displaced through trap muscle
For type 4,5,6 separation of an AC joint injury, how is it immediately managed? Progression?
- Surgically managed
- Progress toward full ROM/strength
- Manual therapy as appropriate
- Scap stab/proprioceptive training
Scapular dyskinesia is defined as abnormal movements to the scapula, including:
Decrease:
- posterior tilting
- Upward rotation
- Clavicle retraction
A hyperactive ____ muscle and impaired motor performance of ____ muscles can lead to scapular dyskinesia
- Hyperactive upper trap
- Impaired motor performance
- Lower & Mid Traps
- Serratus Anterior
Diminished soft tissue extensibility/flexibility of what can cause scapular dyskinesia?
- Pec minor
- Posterior capsule tightness - push head of humerus anterior
- Levator scap, lats, GH ER
What is calcific tendonitis of the rotator cuff?
Females (>/
Calcification of the tendons - biceps/supraspinatus tendons
Females>males
What is rotator cuff tendinosis?
Microtrauma
What tissue abnormalities can lead to Subacromial Impingement of the rotator cuff?
- Anatomic abnormalities of acromion
- Bursitis
- Calcific bone spur
- Tendon thickening
What other abnormalities can lead to Subacromial Impingement of the rotator cuff?
- Altered scapulothoracic/scapulohumeral kinematics
- Postural abnormalities (foreword head posture and rounded shoulders)
- Superior translation of humeral head during elevation
- Decreased GH joint stability
- “tight” posterior capsular
What is the typical clinical progression of tendonitis of the rotator cuff?
Tendonitis -> degenerative tendinopathy ->partial thickness tear ->full thickness tear
What is the goal when working with a patient who has tendonitis of the rotator cuff?
stop movement to later stages
What symptoms/functional activities are difficult for patient with rotator cuff tendinopathy?
- Dull ache lateral upper/ lower arm
- Reaching away from body painful
- Abduction difficult
- Over shoulder-level activities painful
Where is the common pain distribution of rotator cuff tendinopathy?
Lateral proximal upper arm
Why is there a possibly painful GH arc when lifting arm above head? What is the degree of arc?
where we need posterior tipping but it’s lacking
60-120 deg of shoulder elevation
T/F Tender at tendon insertion of rotator cuff tendinopathy.
True
With a patient with rotator cuff tendinopathy, where will we see muscle guarding?
Muscle guarding peri-scapular musculature (traps)
With a patient with rotator cuff tendinopathy, where will we see muscle tightness?
Pec minor
With a patient with rotator cuff tendinopathy, where will we see decreased capsule length?
Posterior
With a patient with rotator cuff tendinopathy, where will we see muscle performance impairments?
Serratus anterior and lower trap
T/F Long-Term outcomes of surgical management are comparable to conservative intervention for rotator cuff tears
True, Persistent pain/ disability > 1/3 of patients (regardless of Tx)
What type of resistance (if any) used on Traumatic tear vs degenerative tear of rotator cuff?
- Traumatic tear (no resistance testing)
2. degenerative tear (gradual process, total absence of resistance during MMT)
Physical examination of rotator cuff tears:
- Significant weakness with shoulder (limited AROM, weak/ absent shoulder resistance testing)
- Compensation with scapular motion when attempting to elevate UE (skipping supraspinatus downward motion on humeral head)
With older adults >60 postural changes, you see more thoracic kyphosis which can lead to what changes to the humeral head?
humeral head more anterior -> not as good posterior tipping of scapula and impingement occurs
What is the critical zone for older adults >60 in regard to their rotator cuff?
supraspinatus is no longer vascular so when tearing starts, it can not repair
Infiltration of what into the supraspinatus and infraspinatus muscle tears that will influence rotator cuff strength and is a negative prognostic factor?
Fatty infiltration
Biceps tendon instability is commonly associated with what muscular tears?
subscap tears (inability to hold humeral head in anterior motion)
Bicep tendon tendinopathy mechanism?
microtrauma
Bicep tendon tendinopathy tender where?
in bicipital groove
Bicep tendon tendinopathy pain with what (tests)?
with tensile loading (MMT supination, flexion, Yorgason’s test, speed test)
Rupture of the biceps tendon commonly occurs where?
occur at origin or upon exit of bicipital groove
Common presentation of a bicep tendon rupture?
- Popeye deformity (bulge, biceps muscle retracts distally)
- Most commonly age > 50 years
- Hx biceps tendinosis
What is adhesive capsulitis?
pathological process that effects capsule – irritation, synovial hypertrophy
What is the incidence of adhesive capsulitis?
a. Incidence 3-5 %
b. Women > Men
c. 5th and 6th decades of life
What are risk factors for adhesive capsulitis?
i. DM (5-6x more likely)
ii. Prior history in either shoulder
What is the normal progression of adhesive capsulitis (how many years)?
Normal function regained ~ 2 years following onset
Describe adhesive capsulitis stage 1: pre-adhesive
(0-3 months)
- Early loss of ER ROM with intact strength
- hyper vascular, hypertrophic synovitis; and normal capsular tissue
Describe adhesive capsulitis stage 2: freezing stage
(4-12 months)
- Multidirectional motion loss
- “thickened, hyper vascular synovitis described as having a Christmas tree appearance”
- Loss of axillary fold (necessary so humerus can drop down in elevation – if not bicep tendon, bursa aggravation)
Describe adhesive capsulitis stage 3: 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 adhesive capsulitis stage 4: Thawing
15-24 months
- Symptoms
a. Minimal pain
b. Gradual return in ROM
c. Stiffness may remain - Tissue: Fibrosis remain, receding synovial involvement
What are the pharmacologic medical interventions for adhesive capsulitis?
NSAIDs, oral steroids (decrease inflammatory response early stages)
What is MUA for adhesive capsulitis? What are the increased risk? What is the goal?
MUA (manipulation under anesthesia – opening capsule up)
- Increased risk for: fracture (humerus), subscapularis rupture, labral tear, and biceps tendon injury
- Goal: Get them into clinic soon to maintain ROM up
What is Hydro dilatation (Brisement) for adhesive capsulitis?
using fluid to stretch joint out within
What is arthroscopy for adhesive capsulitis?
going in with scope to clean out area, open up capsule areas to promote increase ROM
What is open release for adhesive capsulitis?
incision to access capsule (more tissue damage)
OSTEOARTHROPATHY of the Glenohumeral Joint is more commonly seen in patients who:
- Have Hx of shoulder injury/chronic pain
2. Older age
What is the symptom of OSTEOARTHROPATHY of the Glenohumeral Joint?
Anterolateral shoulder pain
What are you looking for in the physical exam of OSTEOARTHROPATHY of the Glenohumeral 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 with traction mobilization
T/F OSTEOARTHROPATHY of the AC Joint can cause concomitant impingement syndrome and/ or rotator cuff tendinopathy.
True
What are the symptoms of OSTEOARTHROPATHY of the AC joint?
i. Pain local to area of ACJ
ii. Painful with overhead activities (full elevation) /reaching across trunk
What are you looking for in the physical exam of OSTEOARTHROPATHY of the SC joint?
i. Focal tenderness ACJ line
ii. Painful/ limited shoulder AROM (elevation, horizontal adduction)
iii. Hypomobility of ACJ
What is AMBRI of a hypermobile shoulder?
Atraumatic Multidirectional Bilateral for Rehabilitation and possibly Inferior capsular shift surgery (generally hypermobile throughout entire body, CT disease)
What is TUBS of a hypermobile shoulder?
Traumatic Unilateral Bankart needing/ responding to Surgery
What are the common MOI of posterior shoulder hypermobility?
- Seizure
- electric shock
- trauma (diving into pool, MVC)
What are the symptoms of posterior shoulder hypermobility?
- Symptoms of instability with shoulder in flexed/ abducted position (pushing door open)
- Pain severe
What are you looking for in the physical exam of a posteriorly hypermobile shoulder?
- Limited/ painful shoulder AROM (ER, elevation)
2. Observable prominence posterior shoulder
What is the common MOI of inferior shoulder hypermobility? What symptom?
Carrying heavy object by side
Pain
What are you looking for in the physical exam of an inferiorly hypermobile shoulder?
- Shoulder locked in abducted position
2. Sulcus observable (gapping at lateral joint line)
What is the most common direction of GH dislocation?
Anterior (the least stable)
What is the common MOI of anterior shoulder hypermobility?
abduction/ ER/ extension
What is the symptom of anterior shoulder hypermobility?
- Feeling of shoulder mal-placement following acute event
What are you looking for in the physical exam of an anteriorly hypermobile shoulder?
- Observed self-immobilization by patient (slightly abducted/ externally rotated)
- Spasm/ guarding to stabilize the joint
- Positive instability tests (modified relocation test)
- Possible hypomobility of posterior G-H capsule
- Painful/ limited AROM
- Painful/ limited/ guarded PROM
What is a Hill-sacks lesion, a potential complications of anterior dislocation?
compression of the posterior humeral head secondary to impaction of glenoid
What is a Bankart lesion, a potential complications of anterior dislocation?
Avulsion injury of anterior inferior labrum
+/- capsular injury
What are the presentations of a Bankart lesion?
a. Clicking/ clunking/ popping/ locking
b. Deep shoulder pain
c. Hx trauma (dislocation), recurrent subluxations
T/F There is not a greater risk among young athletes subsequent glenohumeral dislocation following initial dislocation.
False, there is
a. <20 y/o: 70-85%
b. 20-40 y/o: 50-70%
c. > 40 y/o: 10-15%
Multi-directional instability of the shoulder joint
- Hypermobility syndrome
- Pt may report ability to sublux G-H joint at will
- Repetitive stress can increase risk of degenerative changes to rotator cuff, joint surfaces, and other bony/soft tissue structures
What is a SLAP lesion?
Superior Labral lesion that are both Anterior and Posterior (bicep tendon inserts)
SLAP lesions are associated with what type of athletes?
Overhead athletes
T/F Patient with SLAP lesion commonly presents with concomitant rotator cuff lesion.
True
What is the presentation of a SLAP lesion?
- Aggravation with repetitive overhead activities
- Hx FOOSH/ traction trauma
- Glenohumeral IR ROM limitations
- Muscle performance impairments (scapulothoracic, scapulohumeral, rotator cuff)
- Locking/ clicking/ popping/ catching with shoulder motion
- Most often concomitant rotator cuff/ intra-articular/ biceps tendon/ ACJ injuries
Describe a type 1 SLAP lesion
Fraying and degeneration of the superior labrum with a normal biceps tendon anchor
Describe a type 2 SLAP lesion
Fraying of the superior labrum, but hallmark is pathologic detachment of labrum and biceps anchor from superior glenoid
Describe a type 3 SLAP lesion
Superior labrum has vertical tear analogous to bucket-handle tear
Remaining rim of labral tissue is well anchored to glenoid and biceps anchor is intact
Describe a type 4 SLAP lesion
Vertical tear of superior labrum and extends to a variable extent up into the biceps tendon as well
Pitchers with GIRD will exhibit what ER -> IR arc
136.9° ER and 40.1° IR at 90° abduction
Pitchers with GIRD will have an increase in retroversion of how many?
17 deg
Pitchers with GIRD will have stronger what movements? Weaker what movements?
- Throwing shoulder stronger with IR and ADDuction, 2. weaker with ER
The overhead throwing athlete will present with what type of posture?
- Protracted, anteriorly tilted scapula
- Pec minor tightness &/or guarding
- Lower trap weakness
