Shoulder - MSK Flashcards
Impingement Syndrome
-One of the most common complaints regarding the shoulder (“Bursitis”)
-Etiology: Compression of the subacromial
bursa underneath the acromion
Typical history:
-Unknown mechanism of injury
-Repetitive use
-Type I-III Acromion: shape
-Location: Anterior & lateral based shoulder pain
-Quality of pain: Crepitation with movement, Dull to sharp
-Aggravating factors: Pain with overhead/outstretched movements, Nighttime pain – more likely associated with rotator cuff pathology.
-Full range of motion (albeit painful), Typically pain is elicited in the “impingement arc” from 30 to 150 degrees in forward flexion.
-Decreased rotator cuff strength, Occasionally associated rotator cuff pathology, Untreated impingement can cause a RC tear due to attritional changes
-Palpable crepitation
-Positive Hawkins-Kennedy
Tx
-Physical therapy +/- a subacromial injection.
-Nighttime pain – lower threshold for injection
-AT least 3 months between cortisone injections, no more than three injections annually (Rotator cuff breaks down and can develop an attritional tear)
-Referral for surgical intervention, If failed conservative treatment. Get MRI prior to referral
AC joint Injuries
-Typically traumatic
-Direct mechanism: Fall onto tip of shoulder, “checked” into boards in hockey
-Indirect mechanism: Fall onto the elbow
-AC Separation: Involves the CC (coracoclavicular) ligaments and the AC (acromioclavicular) ligaments
-Inspection: Bony deformity (especially Grade III and above)
-Palpation: Tenderness directly over the
AC joint
-Range of motion: Painful arc, Very painful cross body adduction & internal rotation behind back
-X-ray of BILATERAL AC joints
-Measure the distance from coracoid to inferior aspect of clavicle to determine severity of injury, Greater than 100% displacement classifies Grade III
AC joint injuries TX
- Grade I & II treated conservatively
- Sling for acute pain relief
- Activity modification
- Return to activity will full resolution of symptoms within 2 weeks
- Grade III
- Controversial
- Trend toward non-operative
- Operative in young patients and overhead laborers
- Grade IV-VI
- Reconstruction of anatomic AC joint using a tendon graft
- Restores function
- Restores appearance
Non-traumatic AC joint pain
- AC joint osteolysis (“weight-lifters shoulder”)
- AC joint osteoarthritis
- Responds well to cortisone injection
- If pain returns after injection and appropriate rest – repeat injections usually NOT indicated
- Surgical procedure, distal clavicle excision can provide a permanent solution.
SC joint injuries
- History: Fall on outstretched hand, MVA
- Physical exam: Prominent/tender SC joint, Pain with movement of the ipsilateral arm, Posterior dislocation can cause a choking sensation, difficulty breathing, venous engorgement.
- SC joint sprain, minor subluxation: Treated conservatively, Sling, progressive return to activity, Occasional fluoro-guided cortisone injection for persistent pain
- SC joint dislocation
- Anterior: Closed reduction, Occasionally irreducible – permanent deformity
- Posterior, Medical emergency due to vascular structures, Requires reduction in OR – possible surgical intervention
Adhesive Capsulitis
“Frozen Shoulder”
- Risk Factors: Diabetes, Hypo/Hyperthyroidism, Age >50, Female >Male, Prolonged immobilization
- History
- Pain: Can be post-traumatic, but often insidious, Pain almost always precedes loss of motion, Nighttime pain
- Loss of motion: Common complaints of “unable to reach bra strap” in women and “unable to reach wallet” in men.
- Physical Examination:No specific tenderness on exam, Limited active ROM due to pain, Passive ROM limited with painful endpoints
- Imaging: MRI shows thickening of inferior capsule
Phases of Adhesive Capsulitis
Phase I - “Freezing” (2-9 months)
- Painful phase – precedes loss of motion
- Pain not related to activity
Phase II – “Frozen” (3-9 months)
- ROM progressively limited
- Pain typically not as severe as Phase I
Phase III – “Thawing” (12-24 months)
- Slow progressive return of motion
- Pain continually declines
Adhesive Capsulitis Tx
- If early from symptom onset: Fluoroscopically guided glenohumeral injection
- Physical therapy: Can accelerate the healing process, Slow steady increases in ROM are beneficial, Aggressive therapy can cause a counterproductive effect, Used as an adjunct to GH injection
- Control underlying medical risk factors: Diabetes, thyroid
- Surgery (NEVER in stages I & II)
Thoracic Outlet Syndrome
-Pain, weakness and pallor in the extremity due to compression of the neurovascular bundle in the thoracic outlet (area between the clavicle and first rib)
-History:Positional Numbness/Weakness replicated with overhead movements, Typically dermatome pattern to numbness, Pallor can also be experienced
-Physical Exam: Adson’s Test -Pulse significantly decreases with head rotated/extended to the side that pulse is being tested on with concurrent deep inhalation., Returns when head becomes neutral
-Occasionally caused by a cervical rib: 1 in 500 people, Traverses the thoracic outlet
Treatment
-Physical Therapy: Goal of altering the dynamic thoracic outlet to decrease compression
-Injections: To decrease inflammation in a muscle causing compression, Botox vs. Cortisone
-Surgery: Rarely indicated, Significant risk factors
