shoulder pathologies and upper limb nerve entrapments Flashcards
who is normally affected by shoulder instability?
teenage to 30s
- young
- sporty
- mostly traumatic !
also commonly seen in older people with rotator cuff tears
what type of shoulder instability are there?
posterior and anterior dislocation
what is more common; an anterior or posterior dislocation?
anterior dislocation (95%) is more common compared to posterior dislocation (5%)
when does anterior dislocation typically occur?
during sports and it is usually traumatic
when does a posterior dislocation typically occur?
-epileptic fit or electrocution
what is the treatment for acute shoulder instability?
reduction in emergency department:
- Kocher method
- Hippocratic method
- Stimson method
2-3 weeks sling
- Analgesia
- Gradual early mobilisation
- Physiotherapy
what does shoulder instability look like?
abnormal shoulder contour
in chronic there is often muscle wasting
what does shoulder instability feel like on examination?
tenderness
muscle spasm
what tests should be done for someone with shoulder instability?
- rotator cuff strength
- apprehension test
- relocation
- general laxity
what investigations are done for shoulder instability?
- general exam
- XRAY :AP shoulder and garth views
- MRI arthrogram
what are some injuries associated with shoulder instability?
Labral lesion (Bankart)
Fracture humeral head (Hill Sachs)
Fracture of glenoid (Bony Bankart)
Rotator cuff tear (older patients >40)
what is the instability rehab plan?
6 week sling
8-10 weeks no driving
12 weeks no heavy lifting
can return to non contact sport in 12 weeks
can return to contact sport in 6 months
how long should patient not drive after shoulder instability?
8-10 weeks
how long should a patient wait before heavy lifting after shoulder instability?
12 weeks
when can a patient return to sport after shoulder instability?
non contact= 12 weeks
contact= 6 months
what patients with shoulder instability need surgical repair?
those with a labral tear (Bankart)
most patients
what is impingement syndrome?
pain originating from the sub-acromial space
what does impingement syndrome suggest <30?
- rotator cuff tendonitis
- subacromial bursitis
what does impingement syndrome in 30-40s suggest?
- Calcific tendonitis
- Early tendinosis
what does impingement syndrome in 40-50s suggest?
- Tendinosis
- partial tears rotator cuff
what does impingement syndrome suggest in 50-60s?
cuff tear
what does impingement syndrome in 70s suggest?
-cuff arthropathy
what are specialty tests for impingements?
- Hawkins
- Jobe’s
what investigations are done if there is impingement?
XRAY- AP shoulder and garth views or outlet view
USS
MRI- if patient has difficulty moving shoulder
what is the treatment for impingement?
- rest (avoid doing exercises that hurt)
- oral pain relief
- physio
- cortico steroid injections in subacromial space (x2 at most)
at least 6 months non operative treatment
-decompression surgery
what is the impingement rehab after decompression surgery?
sling 1-2 weeks
early PT and ROM exercises
RC strengthening
usually takes about 6 months to work
what is impingement linked with on examination?
- painful arc
- positive impingement test
who is impingement usually seen in?
30-40
who are cuff tears usually seen in?
50-60
grey hair=cuff tear
how do cuff tears normally present?
- pain
- weakness mainly in overhead activity
what specialty tests should be done for someone with suspected cuff tears?
- supraspinatus
- Gerber’s lift off
- Horn blowers
what investigations are done for someone with suspected cuff tear?
XRAY
USS- if range of movement allows it
MRI - if stiff
what is the treatment for cuff tear?
- rest
- analgesia
- sling
Acute:
- urgent investigation
- early physio
- early reassessment
- early intervention
- arthroscopic or open repair of RC
what is the cuff repair rehab?
- sling 6 weeks
- no driving 8-10 weeks
- 12 weeks no heavy lifting
- prolonged physiotherapy
recovery can take 6-9 months
what % of repaired cuff rotators re tear in the next year?
20-40%
what is frozen shoulder?
- primary idiopathic problem
- shoulder is painful and stiff for months sometimes years
what age group is usually affected by frozen shoulder?
40-50s
what sex is usually affected by frozen shoulder?
more common in females
what other diseases does frozen shoulder have an association with?
diabetes, lipid and endocrine disease and Dupuytren’s
what is the pathophysiology of frozen shoulder?
- contracture and thickening of coraco- humeral ligament which tightens the rotator (which sits in between the supraspanous and subscapularous) and the axillary fold
- decreases joint volume and makes the shoulder tighter
frozen shoulder is an adhesive process.
TRUE or FALSE
FALSE!! :00
how does frozen shoulder usually present?
- pain at rest
- pain at night
- anterior pain
- stiffness
- global restriction in ROM
- external rotation <50% of normal
what are the possible diagnoses if there is a lack of external rotation in the shoulder?
- locked posterior dislocation
- glenohumeral arthritis
- frozen shoulder
what does frozen shoulder look like on radiograph?
normal
what is the treatment for frozen shoulder?
Non operative:
- gentle movements
- analgesia
- physio
- glenohumeral steroid injections
- fluoroscopic distention
Operative:
- manipulation under anaesthetic
- arthroscopic capsular release
what is the rehab for frozen shoulder after surgery?
- sling for short period
- pain control
- AGGRESSIVE physioooooooo
what age group is glenohumeral osteoarthritis usually found in?
> 60s
how does glenohumeral arthritis usually present?
- gradual onset
- pain at night
- stiffness
- intermittent exacerbation
- functional difficulties
- asymmetry
- muscle wasting
- limited external rotation
- global restriction in movement
- pain throughout ROM
what would an Xray of someone with glenohumeral osteoarthritis look like?
- joint space narrowing
- subchondral sclerosis
- subchondral cysts
- osteophyte formation
what is the treatment for glenohumeral osteoarthritis?
non operative:
- analgesia
- physiooooo
- GH steroid injection
operative:
- shoulder replacement (arthroplasty)
- resurfacing
- total shoulder arthroplasty
- reverse polarity shoulder arthroplasty
what is the post arthroplasty rehab?
-sling 6 weeks 8-10 weeks NO DRIVING! -physiooooo -no heavy lifting for 12 weeks -pain relief
what is the median nerve neuropathy?
carpal tunnel syndrome
what is the median nerve neuropathy?
carpal tunnel syndrome
what is the ulnar nerve neuropathy?
cubital tunnel syndrome
who is usually affected by carpal tunnel syndrome?
>30s female pregnant hypothyroidism diabetes obesity RA
why do patients feel pins and needles if they have carpal tunnel syndrome?
due to the relative reduction in blood supply to the median nerve
what would an intrinsic cause of reduction in blood supply to median nerve be? (carpal tunnel)
diabetes
what would an extrinsic cause of reduction in blood supply to median nerve (carpal tunnel syndrome) be?
pressure put on the nerve due to swelling e.g. synovitis
what hand muscles does the median nerve innervate?
LOAF!!
Lateral two lumbricals
Opponens Pollicis
Abductor Pollicis brevis
Flexor pollicis brevis
what are some carpal tunnel signs?
- thenar atrophy
- altered sensation thumb, index, half of middle
- weakness of abductor pollicis brevis
what special tests would be conducted on someone with suspected carpal tunnel?
Durkan’s test- compression
Tinnel’s test- tapping
Phalen’s test- volar flexion
treatment for mild/moderate carpal tunnel syndrome?
- splintage
- physio
- steroid injection
treatment for severe carpal tunnel syndrome?
-carpal tunnel decompression
what is the rehab for carpal tunnel decompression surgery?
- 2 days to reduce dressing
- 5 days to keep dry
- 10 days for sutures
- 6 weeks return pincher grip
- 12 week grip strength
who is more commonly affected by cubital tunnel syndrome?
> 30s
males
what can cause cubital tunnel syndrome?
- post traumatic causes
- direct causes (cysts, tumours)
- arthritis
what muscles does the ulnar nerve innervate in the hand?
All other muscles in hand (all muscle but LOAF):
- ulnar two lumbricals
- all hypothenar muscles
- deep head FPB
- adductor pollicis
how does cubital tunnel syndrome present?
Early:
- pins and needles
- pain
- clumsiness
Late:
- numbness
- weakness
what are the signs for cubital tunnel?
- hypothenar and interosseous atrophy
- clawing of ring and small finger
- altered sensation
- weakness And dig minimi
- weakness of grasp and pinch
- Wartenbergs sign (abducted small finger)
what are the signs for cubital tunnel?
- hypothenar and interosseous atrophy
- clawing of ring and small finger
- altered sensation
- weakness And dig minimi
- weakness of grasp and pinch
- Wartenbergs sign (abducted small finger)
what special tests are done for cubital tunnel tests?
- Tinnels test (tapping)
- Modified Phalen’s test (elbow flexion test)
- Froments test (thumb flexion during key grip)
what are investigations for cubital tunnel?-
- clinical examination
- nerve conduction studies (NCS) and electromyogram (EMG)
what is treatment for cubital tunnel?
mild/moderate:
- elbow splintage
- physiotherapy
- NSAID
Severe:
-ulnar nerve decompression
what is the rehab plan after cubital tunnel decompression surgery ?
- 2 days reduce dressing
- 5 days keep dry
- 10 days for sutures
what are the three stages of frozen shoulder?
FREEZING STAGE- any movement of shoulder causes pain, and shoulder’s range of movement starts to become limited.
FROZEN STAGE- pain may get slightly better at this stage. However, shoulder becomes more stiff and increasingly difficult to use.
THAWING STAGE- range of motion in shoulder begins to improve
