Shoulder Exam Flashcards
1
Q
Order of shoulder exam (5)
A
Observe AROM Palpate Contract Stretch
2
Q
How man tender spots are we looking for in our exam of the shoulder?
A
4
3
Q
When taking a history for a shoulder case, what are 3 possible categories of injury?
A
- Single traumatic event
- Obvious overuse injury
- Idiopathic (sometimes postural)
4
Q
When single traumatic event is implicated, a detailed mechanism including what 3 factors are useful?
A
- Activity
- Estimated force
- Force vectors
5
Q
A fall on the side of the shoulder. What two conditions are on your ddx?
A
AC sprain
Contusion
6
Q
FOOSH injury - what are 3 possible ddx?
A
Labrum tear
AC sprain
RTC injury
7
Q
When asking aggravating and relieving factors during the history of a shoulder exam, what 3 specific questions should you ask?
A
- Specific shoulder movements
- Loading (i.e. OH activities)
- Pulling/lifting motions
8
Q
What would P with OH activities be indicative of?
A
Impingement syndrome
9
Q
What would P with pulling/lifting motions suggest?
A
Possible biceps tendinopathy
10
Q
Are neurological symptoms commonly associated with shoulder pain?
A
No
11
Q
What would the presence of neurological symptoms (weakness, P, paresthesia, concomitant neck pain) distal to the shoulder suggest?
A
Radical are, plexus or peripheral nerve injury causing should pain OR is associated with it
12
Q
What does the physical exam begin with? (2)
A
Observation
AROM
13
Q
What does observation and inspection include? (11)
A
- Symmetry of cervical and shoulder region
- Shape
- Contours
- Texture
- Tone
- Color
- Location
- Changes that occur with body positions changes between relaxed and contracted muscles
- Involuntary movements
- Facial expressions
- Vocal responses
14
Q
Clinical tip: both shoulders including what should be exposed and compared?
A
Scapula! Duh
15
Q
Shoulder AROM includes (5) + 1 complex AROM
A
F/E Ab/Ad IR/ER (@ 90' abduction) Horizontal Ad/Ab Empty can Apley's I and II.
16
Q
Of the shoulder AROM + complex AROM, which must be viewed from behind with scapula exposed? (2)
A
Ab/ad
Apley’s scratch I + II
17
Q
After AROM, what comes next?
A
Muscle assessment
18
Q
What are the 3 aspects of muscle assessment toolkit?
A
Palpation
Stretching
Contraction
19
Q
What do you include in your palpation in the muscle assessment toolkit?
A
Muscle/tendon UNDER LOAD and in relaxed position
20
Q
What is the purpose of putting the muscle of suspicion under stretch? (4)
A
Detect pain
Limited motion
Tightness
Altered end feel
21
Q
What do yo include in contraction of muscle assessment toolkit? (4)
A
Isometric manual muscle test
Resisted ROM (concentric/eccentric)
Through PNF cross pattern
Mimicking ADL/sport
22
Q
Once identifying a painful tendon/muscle, what is on your ddx? (8)
A
Tendinopathy/osis Small-medium partial tendon tears Large tears/rupture Muscle strains (GI-III with 3 being rupture) Contusion Myospasm MFTP (aka myofascial pain syndrome) Myopathy
23
Q
Tendinopathy can be result of what diagnosis? Especially what 2 structures
A
Impingement syndrome.
Supraspinatus or long head of the biceps
24
Q
Besides static palpation for tissue tenderness and observing for misalignment, what is used to assess for joint dysfunction of the shoulder?
A
Motion palpation (joint glide assessments) for pain and restrictions
25
How are the joint play maneuvers usually done?
Open/loose packed position
26
When are plain radiographs used? (3)
Suspect fracture
Disease
Or dislocation
27
Plain radiographs may also be useful in identifying what (4)
ID osseous lesions
ID changes in joint spaces in complicated patients presenting with impingement
Symptoms with a past history of dislocation
Comorbid instability
28
What inexpensive technique is used to evaluate RTC and biceps tendons?
MSK diagnostic US
29
MRI/MRA is best for evaluation of what structures (3)
Labrum, cartilage and ST damage.
30
What is the downside of MRI/MRA
$$
31
WHAT is an excellent alternative when MRI is unavailable or contraindicated.
CT (w/ or without contrast)
32
What views would you include for plain radiograph? (4)
AP IR
AP ER
Y-scapula view
Auxiliary view
33
What additional views would you include for a shoulder evaluation? (3)
PA chest view
Cervical spine view
Grashey view
34
What are some critical exclusionary diagnosis in adult patients with shoulder pain? (6)
```
Osteonecrosis
Septic arthritis
Acute fractures including avlusion
Dislocation
Malignant tumor
Pain radiating from the chest
```
35
What are 4 general indications in recommendation for x-ray?
1. No response to care after 4 weeks
2. Significant activity restriction greater than 4 weeks
3. Non-mechanical pain
4. Red flag indicators for disease or trauma
36
What is meant by non-mechanical pain under general indications for x-ray? (3)
Unrelenting pain at rest
Constant or progressive symptoms and signs
Pain not reproduced on assessment
37
What are 9 red flags for cancer?
1. History of cancer
2. Signs and symptoms of cancer
3. Unexplained deformity
4. Palpable enlarging mass or swelling
5. Age greater than 50 years
6. Pain at rest
7. Pain at multiple sites
8. Unexplained weight loss
9. Significant unexplained shoulder pain with no previous imaging performed
38
What are 7 red flag indicators for infection?
1. Red skin
2. Fever
3. Systematically unwell
4. Immunosuppression (DM, HIV)
5. IV drug use
6. Penetrating wound
7. Underlying disease process that predisposes to osteomyelitis and/or septic arthritis
39
What are 12 red flag indicators associated with shoulder trauma in the adult patient?
1. Acute disabling pain
2. Significant weakness (i.e. Positive arm drop test)
3. Unexplained significant sensory or motor deficit
4. Loss of normal shape
5. Palpable mass or deformity
6. Exam unable to localize structure causing pain
7. Severely restricted shoulder mobility
8. Hx of epileptic seizure or electrical shock
9. Hx of non-investigated trauma
10. First-time dislocation
11. Blunt trauma
12. Age > 40 years
40
What are 3 of his stupid examples of blunt trauma under red flag indicators associated with shoulder trauma in the adult patient?
1. Fall greater than 1 flight of stairs
2. Fight/assault episode
3. MVA
41
Can a negative tuning fork rule out a fracture?
No!
42
Is age by itself a strong indicator for cancer or need for a radiograph?
No!
43
MSK diagnostic ultrasound produces what images
High resolution images
44
How does MSK diagnostic ultrasound work?
Uses sounds waves to create images
45
List risk factors for MSK diagnostic ultrasound
None!! Tricked ya
46
What can be used when MRI is contraindicated in ST issues?
MSK diagnostic ultrasound
47
Is there radiation involved in MSK diagnostic ultrasound?
No. this is why it can also be used repeatedly
48
Some examples as to where MSK ultrasound would be beneficial? (6)
```
RTC
Calcification or non-calcification tendonitis
Subacromial bursitis
Joint effusion
Impingement syndrome
```
49
Glenoid labrum and synovial cavity are best delineated by what two imaging modalities?
MRI and CT
50
MRI best demonstrates which shoulder pathologies? (3)
Bankart
Ligamentous
Tendinous injuries resulting from dislocation that can lead to instability
51
This modalities is best for identifying sports injuries and thus providing accuracy in diagnosis and preventing injury progression
MSK US
52
Specialist referral and/or specialized imaging (MRI/MRA) even if conventional radiographs are unremarkable is indicated when? (5)
1. Pain and disability > 6months
2. Absence of clinical improvement after 4 weeks of therapy
3. Function doesn't improve or it deteriorates
4. History of instability or severe post-traumautic AC pain
5. Presence of serious pathology found in patient history, exam and/or radiographs
53
Imaging for full tear or large partial tear? (3)
MRI
US
Arthroscopy
54
Imaging for Small partial tear or tendinopathy(2)
MRI or US
55
Imaging for impingement syndrome? (3)
Radiograph
US
MRI
56
Imaging for AC sprain? (1)
Radiograph (weighted and unweighted)
57
Imaging for labrum tear? (3)
MR arthrography
MRI
Arthroscopy
58
Imaging for capsulitis/frozen shoulder?
Arthroscopy
59
Imaging for fracture/dislocation? (1)
Radiograph
60
What radiographic views are used to ddx between grade 2 and 3 injuries?
Stress views
61
MRA (arthrogram) sensitivity, specificity vs. MRI sensitivity and specificity.
MRA; Sp 93%; SN 88%
| MRI: SP 87%, SN 76%
62
When working up a shoulder complaint, what 5 key issues must be addressed?
1. Location
2. Pathoanatomical pain generator/diagnosis
3. Biomechanical/manual therapy diagnosis
4. Directional preference?
5. Kinetic chain contributors/complications?
63
3 options for region of pain in assessment strategy
Shoulder
Neck
Viscera
64
If pain doesn't originate from the shoulder complex, what are the other options? (2)
```
Referred pain from cervical spine and muscles
Viscerosomatic referrals (esp. cardiac)
```
65
What are important tools in making differentiation of pain origin?
History and physical exam
66
What should prompt the doc to look elsewhere for pain generator in PE?
Inability to reproduce shoulder symptoms during PE
67
What sign during active abduction is an indicator that the shoulder is a main pain generator?
Shoulder shrugging DUE TO PAIN
68
Where do lesions in the cervical spine and musculature cause somatic pain referral?
Shoulder and upper arm
69
Cervical radiculitis can also cause shoulder pain? What is a good test to check for this?
Yes
| Simple arm squeeze
70
Describe the simple arm squeeze
Middle third of the arm to compress radial, ulnar and median nerves. Firm palpation at AC joint and anterolateral subacromial area.
71
If the arm squeeze produces more pain than pressure on shoulder, what does this mean?
Cervical radicular lesion is suspected.
72
What cues during a PE should alert practitioners that shoulder pain is of cardiac origin? (7)
1. Age
2. SOB
3. Nausea
4. Palpitations
5. Pre-syncope
6. Dizziness
7. Inability to aggravate or relieve shoulder symptoms during PE
73
MC pain location for MI (give top 2)
1. Both arms with pain
| 2. Right arm with pain
74
MC muscle/tendon pathoanatomical pain generators (3)
1. Full tear/large partial tear
2. Small tear/tendinopathy
3. Impingement syndrome
75
MC Joint/ligament/bone shoulder pathoanatomical pain generators (4)
1. AC (or SC) sprain
2. Bursitis/capsulitis/frozen shoulder
3. Labrum tear
4. Fracture/dislocation
76
First general differential to decide in a shoulder case?
Whether pain is related to RTC TENDONS (+ long head of biceps)
OR
Joint complex
77
MC shoulder problem
RTC lesions
78
MC RTC lesions are in tendon or muscle belly?
Tendon
79
Two challenges practictioner faces in a shoulder case
1. Tendons involved
| 2. Nature of the injury + diagnosing
80
Identifying between grade 2 and grade 3 tears is not necessary?
False, this is critical! Differentiating between grade 1-2 = no big deal. Differentiating between 2-3 = big deal!
81
In conservative care of full RTC rupture, how long is compliance required if this is chosen vs. surgery?
3-6 months.
82
Significant weakness with isometric muscle testing is enough to indicate a large tear or rupture?
False. The body is able to recruit other uninjured muscles to mask the failure of the ruptured tendon
83
Large tears are MC in what age group?
Old
84
Large tears are MC d/t what MOI??
Repetitive microtrauma + age-related degeneration
85
What 3 factors = +LR of 9.8 for large rotator cuff tear?
> 65 years
Night pain
Weakness in ER's at 0 degrees abduction
86
List other tests/signs that support large tear (5)
1. Internal/external lag tests
2. Lift off test
3. Codman's arm drop/dropping sign
4. Can't perform belly presses without considerable compensation
5. Can't perform bugler test without considerable compensation
87
Large ruptures affects management plan. What is the order of steps when a large rupture is suspected? (2)
1. Order MR/US/arthroscopy ASAP
| 2. Consider surgery vs. extended physical rehab
88
What is the first differential when muscle weakness is associated with pain?
Traumatic or repetitive injury of the tendon
89
What else can weakness with pain be associated with besides trauma/repetitive injury? Why?
Pain response d/t internal derangement. The isometric contraction of rotator cuff muscles compress load
90
What would painless weakness indicate? (4)
```
Complete tendon rupture! Or proximal damage to nerve supple to the muscle (ie in spine)
reflex inhibition (d/t MFTP)
disuse or atrophy
```
91
T/f: in some cases, pain may occur during initial set phase loading of the muscle
True
92
Grade 3 weakness is more likely due to what two things instead of simple reflex inhibition or disuse?
1. Major nerve damage
| 2. Tendon rupture
93
Early stage adhesive capsulitis is easy to distinguish from other shoulder conditions?
No! Hard. Also, it may develop as a result of primary shoulder condition or without other shoulder conditions
94
Early stage AC (adhesive capsulitis) has a history of poor response to what 2 treatments?
CMT
| Rehab
95
Early stage AC (adhesive capsulitis) is at increased risk with history of what conditions? (10)
Which one is 5x increased risk?
```
Mastectomy
Cardiopulmonary disease
Diabetes (5x increased risk)
Thyroid disease
CVA
Parkinson's
Radiculopathy or neck trauma
Shoulder trauma
Prolonged bed rest
UE immobilization or tendinopathy/bursitis.
```
96
Early stage capsulitis will present how with passive and active capsular stretch procedures? Especially which direction?
Painful!
| Especially into ER
97
Uncomplicated early stage adhesive capsulitis will present how with isometric contractions?
No pain
98
Is there pain at night with early stage capsulitis?
Yes
99
Is the pain constant/intermittent with adhesive capsulitis
Constant
100
Middle stage adhesive capsulitis hallmark?
ROM restriction with capsular pattern
101
In what particular movements would a middle stage frozen shoulder experience? (3)
Significant restriction in AROM and PROM with PAIN, especially ER and abduction
102
Passive ER is decreased by __%+ in middle stage frozen shoulder
50
103
Will one exhibit pain with middle stage frozen shoulder?
Yes
104
What usually precedes middle stage frozen shoulder?
Acutely symptomatic shoulder condition
105
Pain may gradually subside but motion restriction increases or decreases? With pain presenting at what point of AROM and PROM?
Increase; endpoint pain
106
Late stage frozen shoulder is a marked restriction of what? With or without pain? Especially in what motions?
AROM AND PROM
Without pain
External rotation land abduction
107
What is the classic pattern of late stage frozen shoulder?
Loss of ER > loss of abduction > loss of flexion > loss of IR
ERABFIR
108
A shoulder presenting with impingement syndrome must be evaluated for what ?
Mild instability
109
The clinical impression/diagnosis of impingement syndrome should indicate what?
Structures impinged
110
What is the most common type of impingement syndrome?
Superior impingement syndrome
111
Superior impingement syndrome presents with pain where?
Anterior or lateral shoulder, rarely not posterior
112
Superior impingement syndrome is associated with what movements?
OH activities
113
Superior impingement syndrome is common in what athletes?
Swimmers ("swimmer's shoulder")
114
Superior impingement syndrome presents with what type of pain?
Chronic/recurrent low grade pain
115
Superior impingement syndrome is often associated with other shoulder conditions?
Yes
116
Are any of the individual impingement tests accurate in isolation?
No
117
What are the positive findings in a PE? (6)
Painful arc in flexion or abduction
Positive impingement tests
Pain with ER
Point tenderness over involved structures
Pain with loading or passive stretching of structures
Worse with arm abducted or flexed
118
What are the impingement tests that would present positively in impingement syndrome?
Neer's passive flexion, hawkin's kennedy
119
What structures would present with point tenderness upon palpation in impingement syndrome? (3)
Long head of biceps tendon
Supraspinatus tendon
Coracoacoromial/coracohumeral ligaments
120
At what degree of abduction will you ahve pain with ER in impingement syndrome?
0'
121
What four tests when positive have a +LR of 2.9?
Hawkins kennedy
Painful arc
Pain with resisted ER
Neer and empty can
122
The most diagnostic combo of what 3 tests gave +LR 10?
Hawkins kennedy
Painful arc
Weakness in ER or lag sign
123
What are some less common forms of impingement syndrome? (2)
Internal/posterior
| Subcoracoid impingement of subscapularis
124
Posterior superior cuff and labrum injury is a form of impingement that is common in what demographic?
Baseball pitchers
125
SLAP lesion is what?
Superior labral tear, anterior to posterior
126
What labrum tear is most common?
SLAP
127
Are SLAP lesions stable or unstable?
Either
128
Labrum tears can result from what (2)
High load trauma or repetitive micro trauma (over use)
129
What are some subjective presentations from a labrum tear? (2)
Recurrent catching/locking
| Recurrent painful "click", pop, clunk in shoulder
130
What would you ddx if you had a shoulder that popped, clicked or clunked (2)
Snapping bicepital tendon or AC crepitus
131
Absence of popping, clicking or catching combined with what would rule out a Labral tear (2)
Negative crank or anterior slide
132
Biceps provocation, biceps load, obrien's are good? For labrum tear
No that good when isolated.
133
PCT +LR? For labrum tear
2.81
134
Anterior slide when combined with what = +LR 3.75 for labrum tear
Crank
135
Anterior slide when combined with what = +LR2.75 for labrum tear
Obrien's
136
Passive rotation for labrum tear
Promising test
137
Passive distraction with obrien's test +LR =
7.. good!
138
Crank test showed promise in combo with what
Positive anterior slide test
139
Apprehension and relocation can help rule in a SLAP lesion?
Yes
140
Positive anterior slide combined with what two positive tests are good?
Positive active compression or crank
141
Failure to respond to conservative care may also indicate a labrum tear
True
142
What imaging would you suggest for labrum tear? (3)
MR arthrography
MRI
CT arthrography
