Shoulder (CPG & SR+MA) Flashcards
Adhesive capsulitis - risk factors
- Type 1/2 DM
- Thyroid disease
- Age 40-65 (51-55 peak)
- Female
- immoblization, MI, trauma, autoimmune
High Irritability
- Pain = High levels of pain (7/10)
- Night/resting pain = consistent
- Disability = High (ASES, DASH, PSS)
- Pain before end range (AROM/PROM)
- AROM << PROM
Moderate Irritability
- Pain = moderate (4-6/10)
- Night/resting pain = intermittent
- Moderate disability (ASES, PSS, DASH)
- Pain AT endrange (PROM/AROM)
- AROM = PROM
Low Irritability
- Pain = minimal (<3/10)
- Night/resting = none
- Disability = minimal (DASH, ASES, PSS)
- Pain only with OP PROM
- AROM = PROM
Adhesive capsulitis stages
- Early loss ER
- Freezing (loss all ROM 3-9 months)
- Frozen (9-15 months)
- Thawing (15-24 months)
Subacromial impingement tests
(Hegedus & Beiderwolff)
subacromial impingement
- Hegedus >= 3/5 +LR 2.93, -LR 0.34
- Neer Sn 72% / Sp 60%
- Hawkins-Kennedy test Sn 79% Sp 59%,
- painful arc Sn 53% Sp 76%,
- empty can Sn .30, Sp .74
- infra MMT
- Beiderwolff
- HK, painful arc, infraspinatus MMT
- 3/3 +LR 10.5
- 2/3 +LR 5.03
- HK, painful arc, infraspinatus MMT
Beiderwolff 2013
Algorithm
Objective
- IRRST 90o ABD, 80o ER
- positive = IR << ER, + intra-articular pathology
- capsule instability, lesions, internal impingement
- negative = IR >> ER, +RC pathology
- Sp .96 Sn .86
- +LR 22.0 -LR 0.13
- positive = IR << ER, + intra-articular pathology
- If normal (IR 60% of ER), extra-articular
Beiderwolff 2013
Subjective
Rotator cuff tendinopathy OR
sub-acromial impingement
RC tendinopathy / Sub-acromial impingement
- anterior/lateral pain
- painful arc
- night pain
Beiderwolff 2013
Subjective
Rotator cuff tear
RC tear
- anterior/lateral pain
- compensatory shrugging
- constant achiness
- wake during sleep
- >40
Beiderwolff 2013
Anterior instability
Anterior labrum
Bankart
(subjective)
Anterior instability, Bankhart, anterior labral
- anterior pain, apprehension/pain in ER/ABD
- trauma
- hx of subluxation, “dead arm”
- clicking, locking
Beiderwolff 2013
Posterior instability
Labrum
Posterior instability, labrum
- deep posterior pain
- apprehension/pain with
- pushing and/or
- ADD and/or
- CKC position
- hx posterior/inferior trauma
- clicking/locking/clunking
Beiderwolff 2013
SLAP subjective
SLAP
- deep shoulder pain,
- clicking, locking, clunking
- pain w/ eccentric deceleration and/or loading of biceps
Beiderwolff 2013
LHB subjective
LHB tendinopathy
- anterior pain, TTP LHB
- pain w/ ecentric deceleration and/or loading of biceps
Beiderwolff 2013
AC joint subjective
AC joint
- superior joint pain
- pain w/ end range elevation, ADD
- TTP AC joint
- step-off
- MOI
ASES
- Scale 0-100 (100=no pain/disability)
- Pain & function subscales 50 each
- MCID 6.4 points
- MDC 16.0 points
*
DASH
- 0-100% (higher = more disability)
- 30 questions, 5 point likert
- SEM (4.6-7.6 points)
- MDC 12.2 (10.7-12.8 points)
- MCID 10.2 points
SPADI
- 13 items (pain/function)
- 0-50 points for each section
- 0-100 total score (100=worse)
- MCID 10 points
*
Adhesive capsulities - Interventions
- CSI + MT - strong
- Education - moderate evidence
- Stretching w/respect for irritability level - moderate
- Modalities - weak
- Mobilization - weak (perhaps moderate?)
- MUA - weak
Rule in /out diagnosis of
Adhesive capsulitis
-
Rule in
- 40-65
- gradual onset, progressive worsening ROM
- limited ADLs
- GHJ PROM/mobes limited ER worse than all
- GH ER decrease w/ABD 45–>90
-
Rule out if
- PROM normal
- PROM increases ABD 45–>90
- GH arthritis
- ULTT reproduces sxs
Rule in / out diagnosis of:
Shoulder stability and movement coordination impairments
OR
dislocation or sprain/strain
-
Rule in
- <40
- hx of shldr dislocatin
- excessive GHJ accessory motion
- apprehension flex/abd and/or ER
-
Rule out
- No hx of dislocation
- GHJ motion limitations
- no apprehension
Rule in / out diagnosis of:
shoulder pain & muscle power deficits / rotator cuff
-
Rule in
- sxs developed/worse with repeitive overhead or acute trauam
- midrange catching or arc of pain
- MMT midrange reproduce pain
- rotator cuff msucle weakness
-
Rule out
- resistive tests pain free
- rotator cuff normal strength
- signficant loss PROM
Imaging
- Adhesive capsulitis
- arthrographic < 10-12mL
- MRI
- US (rotator cuff interval)
*
GHJ Ligamentous stability
- Inferior GH ligament
- Anterior band - resists anterior translation (90o ABD, full ER)
- Posterior band - resists posterior translation
- Middle GH ligament
- anterior translation 0-45o ABD
- limits ER at 0o ABD
- Superior GH ligament
- inferior translation (ADD or 0o ABD)
AC joint ligamentous stability
- Conoid coraclavicular
- anterior & superior rotation / displacement
- Trapezoid coracoclavicular
- horizontal & vertical displacement
- Acromioclavicular and joint capsule
- posterior displacement & rotation
Types of rotary cuff impingement
- Primary
- mechanical beneath coracoarcomial arch
- (abnormal structural characteristics)
- Secondary
- relative decrase in space by micro-instability of GHJ / scapulothoracic
- Posterior
- elevated/ER
- undersurface of tendons
- associated with anterior instability
Hegedus 2012
SLAP tears
SLAP tears
-
Rule in and rule out
-
Passive distraction AND active compression
- Sn .70, Sp .90 +LR 7.00 - LR .11
-
Passive distraction AND active compression
- Rule out SENSITIVE:
- Relocation Sn .52
- Rule in SPECIFIC
- Rule in with compression rotation AND apprehension AND speed SP .92, + LR 3.13
- Yeragasons Sp .95
- Compression-rotation test +LR 2.81
- Passive distraction Sp .80%, LR+ ≥ 5.0
Hegedus 2012 - OA/adhesive capsulitis/RC tears
OA/Adhesive capsulitis/RC tears
- Shoulder shrug Sn .80 , LR− ≤ 0.20)
Hegedus 2012 - other high Sn / Sp
Subscapularis tear Sn/Sp
- belly-off and modified belly press tests for bony instability
bony apprehension test for bony instability
bony abnormality
- olecranon-manubrium percussion test
SLAP (Sn/Sp)
- passive compression for a SLAP lesion
RC tear (Sn/Sp)
- lateral Jobe test for rotator cuff tear
Abdulla et al 2015 (OPTIMa) SR
Exercise for
subacromial impingement &
other soft tissue shoulder
Variable duration SIS
- Supervised strengthening = greater short-term imporvement in pain/disability vs. wait list
- supervised/home-based strengthening/stretching = greater short-term improvement in pain/disability vs. no treatment
Persistent duration SIS
- supervised & home-based strengthening = similar outcomes as surgery
- home-based heavy load eccentric training does not add benefit to home-based RC strengthening & PT
Variable duration low-grade non-specific shoulder pain:
- supevised strengthening & stretching leads to similar short-term outcomes as CSI or multimodal care
Desjardin et al 2015 JOSPT
Manual Therapy for RC tendinopathy SR and MA
Overall MT + exercise reduces pain (sig not clinically)
- MT compared with placebo or other
- Decreased pain - pooled effects statistically, not clinically, important (VAS 1.2 95%CI 0.08,1.6)
- MT alone compared with placebo
- Decreased pain, statistically, not clinically important (VAS 1.0, 95% CI 0.6,1.4)
- Improved function 1 RCT (sig not MCID)
- Not necessarily ROM
- MT+EX
- Decreased pain (VAS 1.0, 95%CI 0.7,1.4)
Yu et al (OPTIMa) 2015 PTJ
Effectivess of Passive Physical Modalities for shoulder pain SR
low-level laser more effective than placebo or ultrasound for SIS
shock-wave therapy more effective than sham for persistent shoulder calcific tendinitis
Dong et al 2015 PRISMA SR Medicine
Treatments for SHoulder Impingement Syndrome
excellent for EARLY stage
- Exercise PLUS
- Kinesio taping
- Acupuncture
Consider if exercise not option:
- Standard ASD vs. open arthroscopic bursectomy & open sub-acromial decompression
2.
Goldgrub et al 2016 SR
Effectiveness of Multimodal Care for management of shoulder soft tissue injuries
- Patients with variable duration shoulder pain should be managed with supervised strengthening and stretching (HEP)
- Little evidence that multi-modal care provides superior effectivenss compared with individual interventions for SIS or non-specific shoulder pain
Chester et al 2013 BMC MSK
Predicting response to PT treatment for MSK shoulder pain SR
Two prognostic factors:
- duration of shoulder pain
- longer ASW poorer outcome
- shorter ASW better outcome
- baseline function
- high baelin disability ASW poor functional outcome
- (vice versa not explored)
- age
- older = worse
*
- older = worse
Scapular kinematics
healthy/pathologic
(Ludewig et al JOSPT 2009)
Grp__Healthy__imping/RTC__GHJ instab__Adhesive Cap
1o Up rot Dec up rot Dec up rot Inc up rot
2o Post tilt Dec post tilt - -
3o ER / IR Inc IR Inc IR -
Shoulder force couples
- Deltoid (superior) + infra/supra & teres minor (inferior); supraspinatus –> compressive
- Lower trap / serratus anterior + upper trap / levator scap = upward rotation
- subscap + infraspinatus / teres minor = depression and compression (GHJ –> glenoid)
3 types of scapular dyskinesis
(SICK)
- Anterior tilt
- IR
- Downward rotation
- Scapula malposition
- Inferior medial border prominence
- Coracoid pain & malposition
- dysKinesia of scapular movement
Rotator cuff exercises
(Ellenbecker & Cools BJSM 2010)
- Ellenbecker & cools
- Initial
- Sidelying ER
- Prone EXT (with ER)
- Next
- Prone horizontal ABD
- Prone ER with scap retraction
- Supraspinatus
- Prone horizontal abduction (90o ABD) (NOT empty can)
- Initial
Scapular exercises
- Serratus strengthening / retraining
- low row, inferior glide, lawnmower, robbery
- Upper trap reduction
- Posterior capsule stretching
- Pec minor stretching
- t-spine extension
Supraspinatus Tendinopathy
(Beiderwolff & Hegedus)
- Beiderwolff
- ER lag sign
- Sn 13% Sp 88% +LR 15.5,34.5 -LR 0.2,0.32
- ER lag sign
- Hegedus
- Supraspinatus tear
- >39,painful arc,popping/clicking
- >= 2/3 Sn .75, Sp .81, -LR .32, +LR 3.82
- = 3 Sn .38, Sp .99, -LR .63 + LR 32.20
- >39,painful arc,popping/clicking
- Any RC tear (rule in)
- Age >65 & infra MMT & night pain
- +LR 9.8,
- -LR .54
- Age >65 & infra MMT & night pain
- Supraspinatus tear
Infraspinatus tear
Hegedus & Beiderwolff
- Beiderwolff
- ER lag sign (- -rule out, ++rule in)
- Sn . 69-.98, Sp .98
- Dropping sign (- - - rule out, +++ rule in)
- Sn 1.00, Sp 1.00
- ER lag sign (- -rule out, ++rule in)
- Hegedus
*
Hegedus 2012
Anterior Instability
Anterior Instability
- Rule in AND rule out with
- Apprehension AND relocation
- Sn. 81, Sp .98, -LR .19, +LR 19.68
- Apprehension AND relocation
Primary impingment
Primary impingment
- abnormal mechanical relationship b/t RC & coracoacromial arch
- Hx
- > 40, anterio/lateral upper arm
- unable to sleep on side
- Obj
- dec ROM/strength
- +Neers, HK
- AC arthrosis
- worse with IR & ABD >90
*
Secondary impingement
Secondary impingement
- narrowing of sub-acromial space due to GH or ST instability
- History
- typically younger & overhead
- “arm going dead”
- Obj
- GH instability ri & ro (apprension & relocation)
- +full/empty can
- scap dyskinesia/winging/abnml motion
- tight posterior GH capsule
RC and ST exercises
(Reinold et al JOSPT 2009)
- Supra - full can, prone full can
- Infra/TM - sidelying ER, prone ER 90 ABD, ER w/towel
- Subscap - IR @ 0/90 ABD, IR diagonal
- SA - pushup+, dynamic hug, SA 120o
- LT - prone full can, prone ER 90 ABD, prone H ABD@90oABD w/ER, bilat ER
- UT - shrug, prone row
- rhomboid, levator scap - prone row, prone H ABD@90o ABD w/ER, prone EXT w/ER
