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OCS Ciccarello > Shoulder (CPG & SR+MA) > Flashcards

Shoulder (CPG & SR+MA) Flashcards

1
Q

Adhesive capsulitis - risk factors

A
  • Type 1/2 DM
  • Thyroid disease
  • Age 40-65 (51-55 peak)
  • Female
  • immoblization, MI, trauma, autoimmune
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2
Q

High Irritability

A
  • Pain = High levels of pain (7/10)
  • Night/resting pain = consistent
  • Disability = High (ASES, DASH, PSS)
  • Pain before end range (AROM/PROM)
  • AROM << PROM
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3
Q

Moderate Irritability

A
  • Pain = moderate (4-6/10)
  • Night/resting pain = intermittent
  • Moderate disability (ASES, PSS, DASH)
  • Pain AT endrange (PROM/AROM)
  • AROM = PROM
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4
Q

Low Irritability

A
  • Pain = minimal (<3/10)
  • Night/resting = none
  • Disability = minimal (DASH, ASES, PSS)
  • Pain only with OP PROM
  • AROM = PROM
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5
Q

Adhesive capsulitis stages

A
  1. Early loss ER
  2. Freezing (loss all ROM 3-9 months)
  3. Frozen (9-15 months)
  4. Thawing (15-24 months)
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6
Q

Subacromial impingement tests

(Hegedus & Beiderwolff)

A

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
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7
Q

Beiderwolff 2013

Algorithm

A

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
  • If normal (IR 60% of ER), extra-articular
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8
Q

Beiderwolff 2013

Subjective

Rotator cuff tendinopathy OR

sub-acromial impingement

A

RC tendinopathy / Sub-acromial impingement

  • anterior/lateral pain
  • painful arc
  • night pain
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9
Q

Beiderwolff 2013

Subjective

Rotator cuff tear

A

RC tear

  • anterior/lateral pain
  • compensatory shrugging
  • constant achiness
  • wake during sleep
  • >40
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10
Q

Beiderwolff 2013

Anterior instability

Anterior labrum

Bankart

(subjective)

A

Anterior instability, Bankhart, anterior labral

  • anterior pain, apprehension/pain in ER/ABD
  • trauma
  • hx of subluxation, “dead arm”
  • clicking, locking
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11
Q

Beiderwolff 2013

Posterior instability

Labrum

A

Posterior instability, labrum

  • deep posterior pain
  • apprehension/pain with
    • pushing and/or
    • ADD and/or
    • CKC position
  • hx posterior/inferior trauma
  • clicking/locking/clunking
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12
Q

Beiderwolff 2013

SLAP subjective

A

SLAP

  • deep shoulder pain,
  • clicking, locking, clunking
  • pain w/ eccentric deceleration and/or loading of biceps
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13
Q

Beiderwolff 2013

LHB subjective

A

LHB tendinopathy

  • anterior pain, TTP LHB
  • pain w/ ecentric deceleration and/or loading of biceps
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14
Q

Beiderwolff 2013

AC joint subjective

A

AC joint

  • superior joint pain
  • pain w/ end range elevation, ADD
  • TTP AC joint
  • step-off
  • MOI
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15
Q

ASES

A
  • Scale 0-100 (100=no pain/disability)
  • Pain & function subscales 50 each
  • MCID 6.4 points
  • MDC 16.0 points
    *
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16
Q

DASH

A
  • 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
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17
Q

SPADI

A
  • 13 items (pain/function)
  • 0-50 points for each section
  • 0-100 total score (100=worse)
  • MCID 10 points
    *
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18
Q

Adhesive capsulities - Interventions

A
  • CSI + MT - strong
  • Education - moderate evidence
  • Stretching w/respect for irritability level - moderate
  • Modalities - weak
  • Mobilization - weak (perhaps moderate?)
  • MUA - weak
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19
Q

Rule in /out diagnosis of

Adhesive capsulitis

A
  • 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
20
Q

Rule in / out diagnosis of:

Shoulder stability and movement coordination impairments

OR

dislocation or sprain/strain

A
  • 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
21
Q

Rule in / out diagnosis of:

shoulder pain & muscle power deficits / rotator cuff

A
  • 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
22
Q

Imaging

A
  • Adhesive capsulitis
    • arthrographic < 10-12mL
    • MRI
    • US (rotator cuff interval)
      *
23
Q

GHJ Ligamentous stability

A
  • 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)
24
Q

AC joint ligamentous stability

A
  • Conoid coraclavicular
    • anterior & superior rotation / displacement
  • Trapezoid coracoclavicular
    • horizontal & vertical displacement
  • Acromioclavicular and joint capsule
    • posterior displacement & rotation
25
Q

Types of rotary cuff impingement

A
  • 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
26
Q

Hegedus 2012

SLAP tears

A

SLAP tears

  • Rule in and rule out
    • Passive distraction AND active compression
      • Sn .70, Sp .90 +LR 7.00 - LR .11
  • 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
27
Q

Hegedus 2012 - OA/adhesive capsulitis/RC tears

A

OA/Adhesive capsulitis/RC tears

  • Shoulder shrug Sn .80 , LR− ≤ 0.20)
28
Q

Hegedus 2012 - other high Sn / Sp

A

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
29
Q

Abdulla et al 2015 (OPTIMa) SR

Exercise for

subacromial impingement &

other soft tissue shoulder

A

Variable duration SIS

  1. Supervised strengthening = greater short-term imporvement in pain/disability vs. wait list
  2. supervised/home-based strengthening/stretching = greater short-term improvement in pain/disability vs. no treatment

Persistent duration SIS

  1. supervised & home-based strengthening = similar outcomes as surgery
  2. home-based heavy load eccentric training does not add benefit to home-based RC strengthening & PT

Variable duration low-grade non-specific shoulder pain:

  1. supevised strengthening & stretching leads to similar short-term outcomes as CSI or multimodal care
30
Q

Desjardin et al 2015 JOSPT

Manual Therapy for RC tendinopathy SR and MA

A

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)
31
Q

Yu et al (OPTIMa) 2015 PTJ

Effectivess of Passive Physical Modalities for shoulder pain SR

A

low-level laser more effective than placebo or ultrasound for SIS

shock-wave therapy more effective than sham for persistent shoulder calcific tendinitis

32
Q

Dong et al 2015 PRISMA SR Medicine

Treatments for SHoulder Impingement Syndrome

A

excellent for EARLY stage

  1. Exercise PLUS
  2. Kinesio taping
  3. Acupuncture

Consider if exercise not option:

  1. Standard ASD vs. open arthroscopic bursectomy & open sub-acromial decompression
    2.
33
Q

Goldgrub et al 2016 SR

Effectiveness of Multimodal Care for management of shoulder soft tissue injuries

A
  1. Patients with variable duration shoulder pain should be managed with supervised strengthening and stretching (HEP)
  2. Little evidence that multi-modal care provides superior effectivenss compared with individual interventions for SIS or non-specific shoulder pain
34
Q

Chester et al 2013 BMC MSK

Predicting response to PT treatment for MSK shoulder pain SR

A

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
      *
35
Q

Scapular kinematics

healthy/pathologic

(Ludewig et al JOSPT 2009)

A

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 -

36
Q

Shoulder force couples

A
  1. Deltoid (superior) + infra/supra & teres minor (inferior); supraspinatus –> compressive
  2. Lower trap / serratus anterior + upper trap / levator scap = upward rotation
  3. subscap + infraspinatus / teres minor = depression and compression (GHJ –> glenoid)
37
Q

3 types of scapular dyskinesis

(SICK)

A
  1. Anterior tilt
  2. IR
  3. Downward rotation
  • Scapula malposition
  • Inferior medial border prominence
  • Coracoid pain & malposition
  • dysKinesia of scapular movement
38
Q

Rotator cuff exercises

(Ellenbecker & Cools BJSM 2010)

A
  • 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)
39
Q

Scapular exercises

A
  • Serratus strengthening / retraining
    • low row, inferior glide, lawnmower, robbery
  • Upper trap reduction
  • Posterior capsule stretching
  • Pec minor stretching
  • t-spine extension
40
Q

Supraspinatus Tendinopathy

(Beiderwolff & Hegedus)

A
  • Beiderwolff
    • ER lag sign
      • Sn 13% Sp 88% +LR 15.5,34.5 -LR 0.2,0.32
  • 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
    • Any RC tear (rule in)
      • Age >65 & infra MMT & night pain
        • +LR 9.8,
        • -LR .54
41
Q

Infraspinatus tear

Hegedus & Beiderwolff

A
  • 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
  • Hegedus
    *
42
Q

Hegedus 2012

Anterior Instability

A

Anterior Instability

  • Rule in AND rule out with
    • Apprehension AND relocation
      • Sn. 81, Sp .98, -LR .19, +LR 19.68
43
Q

Primary impingment

A

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
      *
44
Q

Secondary impingement

A

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
45
Q
A
46
Q

RC and ST exercises

(Reinold et al JOSPT 2009)

A
  • 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

OCS Ciccarello (14 decks)

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