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Shoulder complex soft tissue conditions Flashcards

1
Q

common pathologies

A

AC Joint Injury
Frozen Shoulder Contraction Syndrome
Shoulder Instability

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2
Q

which joint is less stable acromioclavicular joint or shoulder joint

A

AC joint

More prone to injury and degenerative changes

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3
Q

types of AC joint injuries

A

levels I-VI

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4
Q

What levels of AC require surgery

A

IV-VI

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5
Q

Identify level 1 AC injury

A

Local pain, swelling and tenderness over the joint

No obvious deformity

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6
Q

how would level 1 AC injury be tested

A

Pain with passive shoulder movements especially horizontal flexion- Scarf test

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7
Q

treatment for level 1 AC injury

A

Initial rest -from aggravating activities, use of analgesics, ice. Start movement after a few days

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8
Q

how would level II AC injury be identified

A

Slight step deformity
Increased pain compared to type 1
Limitation of movement –abduction of the arm >90°.

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9
Q

how would level II AC injury be tested

A

Pain with Scarf Test

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10
Q

treatment for level 1 AC injury

A

Broad-arm sling (elbow supported) for approx 1-2 weeks

Analgesics for pain relief

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11
Q

when will exercise commence after level II AC injury

A

Commence gentle exercise after approx 2 weeks

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12
Q

how would level III AC injury be identified

A

Obvious step deformity

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13
Q

treatment for level III AC injury

A

Treatment:
Sling for approx 2-3 weeks.
Analgesics
Physio post immobilisation

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14
Q

how would level IV-VI AC injury be identified

A

Complete rupture of all ligament complexes
Much rarer
Require surgery

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15
Q

observations made during examination to detect an AC joint injury

A

 step deformity

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16
Q

ROM for AC joint injury

A

Variable – may be limited by pain
Depending on grade
Flexion/Abduction most limited at End of Range (EOR)

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17
Q

palpation for AC joint injury

A

Local tenderness over ACJ

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18
Q

early stage conservative management for AC injury

A

Mx depends on severity
Based on general principles of ligament sprains
POLICE

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19
Q

in the early stage of conservative management of AC injury - how long should the patient rest?

A

Approx 3-4 weeks, but depends on grade

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20
Q

what type of exercises should be prescribed to patients in the later stage of the conservative management of an AC injury

A

Start with gentle active and passive ROM exercises
Strengthening: start with isometric and progress depending on grade and pain
Joint mobs for pain and stiffness at later stage

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21
Q

later stage rest for conservative management of AC injury

A

No return to sport/heavy activity until full pain-free ROM, no tenderness and full strength

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22
Q

surgery for level IV-VI AC injury

A

Insertion of pins, screws
Immobilised for a few weeks post surgery
Following D/C of sling, referral to Physiotherapy
Post-Op Protocol as per Surgeon

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23
Q

frozen shoulder contraction syndrome

A

Condition of unknown aetiology distinguished by painful restriction of shoulder movements, passive and active

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24
Q

how is frozen shoulder contraction syndrome characterised

A

by prominent reduction in gleno-humeral ROM

Other terminology ‘Adhesive Capsulitis’

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25
what age group is affected by frozen shoulder contraction syndrome
40-60 yr olds | mainly women
26
stage I pathology synovitis
Vascular inflammatory synovitis
27
stage II pathology synovitis
Predominance of red synovium with early adhesion formation
28
stage III pathology synovitis
Pink synovium and more pronounced adhesion formation
29
stage IV pathology synovitis
Synovitis disappears, marked white capsular restrictions
30
how is synovitis characterisied
pain - followed by stiffness
31
purpose of X ray investigations in synovitis
Outrule other pathologies e.g. Fracture, avascular necrosis normal or minimal age-related incidental degenerative changes
32
clinical stages
freezing frozen thawing
33
freezing clinical stages time length
10-36 weeks – most severe pain with gradual decrease in articular movement.
34
frozen clinical stages time length
4-12 months – pain decrease with no appreciable increase in movement.
35
thawing clinical stages time length
12 months to years – gradual return of ROM
36
symptoms of freezing stage
Most Painful phase Pain > stiffness Pain at night, cannot lie on that side Pain can be constant, can extend below elbow
37
symptoms of frozen stage
Increasing stiffness but decreasing pain Capsular pattern LAM: most limitation of Lateral rotation > Abduction > Medial rotation more or less muscle weakness
38
capsular pattern meaning
predictable sequence of loss of ROM
39
how can frozen stage be palpated
harder end feel to movement
40
symptoms of thawing phase
Recovery Phase Gradual return of movement- may not return to 100% Less pain, usually at the end of range Between 20-50% can have residual pain and stiffness after this time
41
what does treatment of pathology depend on
depends on stage Pain dominant Vs Stiffness dominant
42
type of medication for pain predominant freezing stage
Corticosteroid Injection Evidence of short-term benefit (Wang et al, 2017) Oral analgesics or NSAIDs
43
physiotherapy for pain predominant freezing stage
Gentle assist active movement Joint Mobilisations (Gr II for pain) Acupuncture-low evidence (Ben-Arie et al, 2020)
44
pros and cons of steroid injections
brings pain down short term but allows patient to do physiotherapy
45
physiotherapy for stiffness predominant injury
``` ROM exercise Passive stretching Joint mobilisations (Gr III for stiffness) AP/PA/inf glides AP good to increase LR ```
46
cons of using manipulation under anaesthetic
poor evidence Risk of haemarthrosis Requires physio afterwards
47
arthrographic hydrodistension
for stiffness predominant (injection of NaCl into GH joint to distend the contracted capsule) Requires physio afterwards
48
prognosis for frozen shoulder AC injury
Average duration of symptoms =30 months (1-3.5 years) Although self-limiting About 10% of patients will have residual shoulder stiffness and disability Up to 4 years later, 41% reported some ongoing symptoms
49
3 types of shoulder instability
traumatic dislocation - torn loose interior instability - worn loose multidirectional instability - born loose
50
shoulder instability
Pathologic increase in translatory movement that interferes with joint function and causes pain
51
factors contributing to shoulder stability
anatomy and dynamic restraints
52
anatomy restraints
Glenoid labrum Ligaments Intra-articular pressure
53
dynamic restraints
Rotator cuff, Long Head of Biceps (LHB)
54
aetiology of traumatic dislocation
Force/fall on externally rotated and abducted arm In the young (<35) can be related to sport e.g. rugby, soccer, gymnastics. In the older (>35) usually related to fall
55
associated lesions of trauamtic dislocation
Tear of capsule Damage to attachment of the labrum to the anterior glenoid (Bankhart lesion) Compression fracture of the posterior humeral head (Hills-Sach Lesion)
56
complications of acute dislocation
Axillary nerve injury Brachial plexus injury Vascular injury (rare) Rotator cuff injury Fracture of the greater tuberosity/ humeral head/ glenoid Recurrent dislocation / instability (long-term)
57
clinical features of shoulder dislocation
``` Loss of deltoid contour Hollow under the acromion Patient holds arm adducted and supported Patient often reports that his shoulder is “out” Arm looks longer Severe pain ```
58
conservative management of shoulder dislocation
Sling and immobilisation 3-6 weeks depending on age of person. In sling: ROM elbow/scapular movement. Advise re washing and dressing Pain is usually not a feature once reduced Progressive strengthening an ROM on r/o sling Sports Specific rehab
59
conservative treatment on removal of sling after dislocation
Assisted active ROM Progress to Active ROM Avoid external rotation initially…why? Ensure normal scapulohumeral rhythm re-established Focus on Rotator cuff, LHB, scapular stabilisers, Deltoid strength Combination of open and closed kinetic chain exercise Functional retraining e.g. Sports-specific Proprioception training
60
closed chain upper limb
upper limb is in contact of object or surface limiting extension of muscle (idk)
61
recurrent dislocation caused by
bankart lesion
62
symptoms of anterior instability worn loose
Pain with throwing- dependent on the type of instability-History of repetitive use, overhead sports Deep pain in shoulder Associated click/clunk with movement Sharp catches of pain through range.
63
worn loose
overstretch capsule - repeated force and overuse
64
typical causes of anterior instability - worn loosed
Bankart lesion Internal Impingement SLAP lesion GIRD
65
signs of anterior instability
Excessive ROM with end- range pain (ER/ABD) May have midrange pain if associated impingement e.g. painful arc Isometrics in midrange are often pain-free and full strength (unless associated impingement) BUT Weak in EOR / instability position (ER+ Abd) stability tests - -hard to evaluate w/ muscle guarding
66
apprehension and relocation
put patient supine abduction/external rotation to point of pain an apprehension can provoke instability - be careful
67
tests for shoulder dislocation
load and shift test ant-post movement | sulcus sign - inferior movement
68
SLAP
Superior Labral Ant to Post where LHB attached. Diff Dx: LHB lesion, Bankart lesion Labral tear
69
subjective feature of labral tears
Assoc with throwing sports, carrying/dropping heavy object. Pain located in posterior shoulder Aggravated by overhead and HBB +/- popping, grinding, catching sensation
70
what would be detected in physical exam of shoulder dislocation
Pain with LHB tests Specific SLAP lesion tests: O’Brien’s test May have positive Apprehension test Confirmed with MRA (better than MRI) and Arthroscopy
71
internal impingement
Impingement of RC against posterior-superior surface of glenoid
72
aetiology of internal impingement
Repetitive trauma | Secondary to labral injury
73
GIRD
Glenohumeral Internal Rotation Deficit (GIRD)

NMSKI (38 decks)

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