Shoulder DDX Flashcards
1
Q
If you suspect a muscle/tendon ddx what are 4 possible pain generator?
A
- large/full tear (grade 3)
- small tear/ tendinopathy (grade 1-2)
- impingement syndrome
- calcific tendinitis
2
Q
If you suspect a joint/lig/bone ddx, what are 4 possible pain generators?
A
- AC (or SC) sprain
- Bursitis/capsulitits/frozen shoulder
- labrum tear
- fracture/dislocation
3
Q
Age >65 AND ext rot weakness AND night pain dx?
A
rupture/large rotator cuff tear
4
Q
+ ext and int rotational lag sign dx?
A
large tear, grade 3
5
Q
+ lift off test, which muscle?
A
subscapularis
6
Q
+ arm dropping sign/drop sign dx?
A
Infraspinatus large tear, grade 3 (may also be associated with supraspinatus rupture)
7
Q
+ napolean’s sign/belly press dx?
A
large tear of subscapularis
8
Q
+ hug test dx?
A
large tear of subscapularis, gr 3
9
Q
+ arm drop/codman’s arm drop dx?
A
supraspinatus tendinopathy, may inclue a large tear
10
Q
+ hornblower’s sign dx?
A
teres minor
11
Q
+ codman’s arm drop AND painful arm AND ER weakness or a lag sign dx?
A
Supraspinatus large tear
12
Q
Age > 39, painful arc, self report of popping or clicking dx?
A
Supraspinatus tendinopathy
13
Q
hx of overhead activities/aggravation, painful arc, neer’s sign, hawkin’s kennedy, ext rotation weakness dx?
A
impingement syndrome
14
Q
What can be impinged ? (3)
A
- supraspinatus
- long head biceps tendon
- subacromial bursa
15
Q
- Severe pain at rest and with movement in any direction
- extreme sensitivity with palpation just inferior to lateral acromion
- Gerber’s/lift off test (he said not to worry about this test)
dx?
- Gerber’s/lift off test (he said not to worry about this test)
A
bursitis
16
Q
Severe pain at rest ddx?
A
acute bursitis, calcific tendinitis
17
Q
- severe pain at rest
- aggravated by ROM in all directions whether active or passive
- possible aggravated by horizontal adduction whether active or passive
- isometric mm test- painless or only mildly provocative
A
C. Capsulitis
18
Q
1.ROM restriction in capsular pattern, sig restriction of AROM and PROM with pain, esp ext rot and abduction
2. preceded by acute symptomatic shoulder condition
3. pain with resisted mm testing
4. pain may have gradually subsided, but motion restriction increases
DX?
A
Frozen shoulder
19
Q
DX?
- Trauma to the clavicle (blow to posteriosuperior point of shoulder, fall on outstretched hand, heavy lifting).
- Swelling, possible deformity (step defect).
- Patient may present with arm cradled in opposite hand.
- Point tenderness
- Pain with active arm raising (flexion or abduction), external rotation, active horizontal adduction.
- Neck and shoulder spasms are common.
- These follow-up tests are recommended: cross body adduction, acromioclavicular resisted extension, and active compression (O’Brien).
A
AC sprain/joint separation
20
Q
DX?
- Traumatic (e.g., sudden or excessive loading) or overuse (e.g., overhead).
- May be isolated, part of impingement syndrome, or associated with anterior instability.
- Anterior shoulder/arm pain exacerbated by lifting, pulling, and overhead activities.
- Point tenderness over tendon (intertubercular groove).
- Pain with biceps resistance: elbow bent, elbow straight (Speed’s test). Unfortunately most of the individual biceps muscle tests are not very accurate.
- Pain with passive stretch (biceps extension test).
- May have positive impingement sign (with external rotation, palm up).
- If the tendon is unstable, history of snapping, positive modified Yergasen’s Test
- May cross react with some labrum tests such as biceps provocation and biceps load,
A
biceps tendinopathy
21
Q
DX?
- hx acute onset of anterior shoulder pain following a popping or tearing sensation
- hx of chronic tendinopathy or steroid injections
- sudden or forceful contraction or sudden stretch
- Weak and painful elbow flexion and/or supination, possibly no pain with contraction if complete tear
- rolled up deformity
- visible swelling or bruising occurs occasionally
A
biceps rupture
22
Q
DX?
- acute excruciating pain, no positional relief, may occur after period of intense use of shoulder
- all AROM are painful
- subtle heat or edema may be present
- passive abduction most painful, followed by passive int. or ext. rotation
- extreme tenderness on palpation
- resisted mm testing may be painful in all directions
A
Bursitis
23
Q
Dx?
- Often very severe pain at rest and intense pain with movement in any direction.
- Pain with most/all AROM; often patient supports injured extremity with opposite hand.
- Nontraumatic (sometimes associated with overuse).
- No fever or signs of systemic disease.
- often middle-aged female, sedentary, nondominant arm
A
Acute calcific tendinitis
24
Q
Dx?
- painful arm in one direction: elevation, flex or abduction or rotation
- may be sx-free, if painful, not as intense and disabling as acute
A
Chronic calcific tendinitis
25
Dx?
Pinpoint pain and crepitus.
Neck pain and neck muscle spasms (especially trapezius).
Localized pain at 90-180 degrees of abduction.
No pain with resisted muscle testing with arm dependent (localized increase in pain with arm abducted, flexed, externally rotated).
Localized pain with passive horizontal adduction and external rotation.
Localized pain with resisted horizontal extension, active compression test (O’Brien’s thumb down), and Paxinos squeeze.
AC DJD
26
Dx?
1 More common in the elderly; characterized by its chronicity and ebb-flow of symptoms.
2 Coarse crepitus.
3 May have history of trauma, surgery, CPPD, chronic shoulder pain, or chronic impingement.
4 Pain may be worse in AM (gel time, 1 hour or less) and then again at end of the day, or after heavy use.
5 Cold weather may exacerbate.
6 Pain in a capsular pattern with passive ROM (external rotation, abduction) may be indistinguishable from/associated with frozen shoulder.
GH DJD
27
DX?
Young person, ext rotation of abducted arms or FOOSH.
- patient antalgic with arm held rigidly in a semi-abducted position.
- all movement excruciatingly painful
- unable to reach across and touch opposite shoulder (Dugas test)
anterior dislocation
28
DX?
MOI are excessive ext rotation of abducted arms or FOOSH with arm flexed and internally rotated
- pt is antalgic with arm held in internal rotation against the body
- all movement excruciatingly painful, esp abduction
- dugas may be neg in posterior dislocation
posterior dislocation
29
Dx?
1. trauma (direct blow, fall direct on shoulder, FOOSH, with pop or crunch
2. local pain, swelling, bruising, point tenderness
3. may have deformity (mid clav), pain with arm raising (flexion or adbuction) lifting or pulling
4. neg tuning fork test cannot be used to R/O a fx
fx of clavicle
30
1. traumatic fall on outstretched hand, on elbow or shoulder, blow to shoulder
2. swelling or bruising near fx site
3. sig pain and point tenderness; occ crepitus on palpation
4. may have deformity or displacement
5. inability to move arm, may be cradled in opposite hand, painful crepitus on movement
6. higher risk in elderly
fx of humerus
31
Dx?
1. hx of poor response to manipulation and rehabilitation may indicate capsulitis
2. hx of mastectomy, cardiopulmonary dz, diabetes, thyroid dz, CVA, parkinson's dz, radiculopathy or neck trauma, shoulder trauma, prolonged bed rest, or upper extremiity immobilization
3. pain with passive and active capsular stretch procedures (esp ext. rotation), no pain with isometric contractions
4. constant pain/pain at night
Frozen shoulder, early stage
32
Dx?
1. ROM restriction with capsular pattern
2. passive external often decreased by 50%
3. usually preceded by an acutely symptomatic shoulder condition
4. may demonstrate pain with resisted muscle testing
5. pain may gradually subside but motion restriction *increases* finally with only endpoint pain during AROM and PROM
Frozen shoulder, middle stage
33
Dx?
1. Marked restriction of AROM and PROM without pain (especially external rotation and abduction).
2. Classic pattern: Loss of external rotation > loss of abduction > loss of flexion > loss of internal rotation.
Frozen shoulder, late stage
34
1 Pain usually anterior or lateral shoulder, rarely posterior.
2 Associated with overhead activities; common in swimmers (“swimmers shoulder”).
3 Chronic/recurrent low grade pain.
4. painful arc
5. + neer's, hawkins-kennedy
6. pain with external rotation
7. pain with loading or passive stretching of supraspinatus and/or biceps
8. worse with arm abducted or flexed
Impingement syndrome
35
Dx?
+ Sulcus sign/reinforced sulcus.
+ Positive Faegin’s sign.
Inferior instability GH jt
36
Dx?
+ anterior apprehension, relocation and release
+ anterior drawer sign
Anterior instability GH jt
37
Dx?
1. + posterior drawer sign
2. + painful posterior shift and clunk with Norwood test
3. + pain with push up/bench press, or resisted forward flexion
Posterior instability GH jt
38
Dx?
1. high load trauma or repetitive micro-trauma
2. recurrent painful click, pop, or clunk in shoulder
3. + biceps provocation and biceps load
4. + o'brien's , passive compression, anterior slide, passive rotation, passive distraction, crank test
Labrum tear
39
+ empty can with resistance
supraspinatus rotator cuff tear/tendinopathy
40
+ hug/napolean
subscap rotator cuff tear
41
bugler's test +
infraspinatus rotator cuff tear
42
dx?
+ pain with passive stretch in opposite direction
+ hawkins kennedy, ext rotator weakness, supraspinatus weakness,
+ pain with AROM
single traumatic event, overuse or postural overload
Rotator cuff tear/tendinopathy
43
dx?
1. Point tenderness, swelling, sometimes bruising (rule out fracture when bruising is present).
2. Pain or crepitus over SC with active or passive abduction or external rotation.
3. Trauma to the clavicle (e.g., seatbelt).
SC sprain
