Shoulder Pathology Flashcards
acromioclavicular joint injuries
defn, causes
AC joint = acromion and clavicle, stabilized by AC ligament (main) and coracoclavicular ligament (minor)
caused by downward force on acromion, e.g. tackles, very heavy lifting
grade 1 = sprain to AC ligament w/o separation
grade 2 = partial separation of AC and CC ligaments
grade 3 = complete separation of AC and CC liagments
acromioclavicular joint injury dx: clinical presentation, physical exam
pain w/ movement and palpation
asymmetry, mild swelling
no special exam
AC joint injury
Note separation of clavicle from scapula, with associated dislocation of humerus
acromioclavicular joint injury
tx and prognosis
pain management (NSAIDs)
immobilization (ranging from therapy tape to bracing depending on severity)
PT for any joint weakness or loss of ROM
grade 3 tears: surgical repair
Good prognosis, w/ return to normal w/in 8 weeks (typical) unless surgery was needed
can cause loss of ROM and nerve impingement
shoulder impingement syndrome
defn and causes
= rotator cuff tendonitis, subacromial bursitis, calcific bursitis
overuse or injury causes microtears to rotator cuff tendons (usually supraspinatus), creating inflammation (bursitis/strain), which could progress to calcification and/or full-thickness tears
“impingement” describes loss of ROM, weakness
acute injury or chronic such as OA spurs
shoulder impingment syndrome
dx: clinical presentation and physical exam
anterior and lateral pain on overhead reaching and shoulder aBduction
positive Hawkin’s test: passive aBduction and internal rotation
shoulder impingement w/ full thickness tear of supraspinatous
note high riding humeral head - moves upward to occupy space previously by supraspinatous, no longer have the ligament holding it down and in place
shoulder impingement syndrome
tx and prognosis
pain management
usually responda to conservative management, consider corticosteroid injection if conservative measures fail
avoid heat in acute phase - inflammation
upper trunk brachial plexopathy
defn and causes
upper trunk = C5/C6 nerve roots
musculocutaneous, axillary, median, radial
weakenss and/or dysesthesias shoulder, arm, forearm, thumb
loss of shoulder aBductors, loss of elbow flexors, loss of wrist extension
“waiter’s tip” = hanging arm, extended elbow, flexed wrist
caused by neck traction, bending, hyperextension
“Erb’s palsy” = during childbirth, motor symptoms (waiter’s tip)
Stingers = later in life, neck hyperextension w/ bending from sports (usually) = typically transient dysesthesias
upper trunk brachial plexopathy
dx: clinical presentation and physical exam findings
weakenss and/or dysesthesias shoulder, arm, forearm, thumb
loss of shoulder aBductors, loss of elbow flexors, loss of wrist extension on PE or observation
“waiter’s tip” = hanging arm, extended elbow, flexed wrist
upper trunk brachial plexopathy
tx and prognosis
Erb’s palsy: no real tx, physical therapy might help a bit
Stingers: usually self-limited
Lower trunk brachial plexopathy
defn and causes
C8 and T1
medial, ulnar nerve
Klumpke’s palsy: caused by forced shoulder aBduction (e.g. hanging injury)
Neurogenic thoracic outlet syndrome (TOS): compression in the space between clavicle and 1st rib, d/t trauma, repetitive arm movement, pregnancy, tumors, anatomical variation
lower brachial trunk plexopathy
dx: clinical presentation and physical exam
motor: claw hand; loss of MCP flexion and IP extension
sensory: dysesthesia down medial forearm and 5th digit
test for neurogenic TOS: ROOS - aBduct, externally rotate, flex elbows (like you’re about to do a pull-up), open and close hands for 3 minutes. Sensitive but not specific.
lower brachial trunk plexopathy
tx and prognosis
not really much of a tx, reduce if possible and PT may help
thoracic outlet syndrome
compression of lower brachial trunk (neurogenic) or subclavian artery (vascular) as it exits through the thoracic outlet (between clavicle and first rib)
ROOS test (raise arms above head like doing pull-up, then flex and extend fingers for 3 minutes) for neurogenic
Adson test for vascular: look up and to affected side, hold breath and check for diminished radial pulse
suprascapular nerve entrapment
suprascapular nerve: upper trunk of brachial plexus –> suprascapular notch (sub-suprascapular ligament) –> supraspinatus and infraspinatus
direct pressure –> entrapment (e.g. backpack)
infraspinatus and supraspinatous are resphonsible for shoulder aBduction and external rotation –> possible weakness, shoulder ache
axillary nerve entrapment
axillary nerve: through axilla –> deltoid
deltoid does shoulder aBduction, so possible weakness here
direct pressure to axilla e.g. crutches
radial nerve injury
radial nerve: through axilla, down humerus in radial groove –> wrist extensors (posterior compartment of the arm) and sensation of dorsal aspect of first 3 digits
entrapment –> wrist drop d/t weakness of wrist extensors, dysthesias across back of hand
direct pressure e.g. “Saturday night palsy” (arm over back of chair), someone sleeping on arm
upper brachial trunk injury
d/t late onset, less likely to be waiter’s tip (Erb’s palsy) and more likely to be Stingers (typically transient dysesthesias down arm - musculocutanous (brachial), medial, and radial (most of posteriolateral aspect of forearm)
associated plexopathy
axillary nerve –> deltoid –> aBduction weakness
lower trunk brachial plexus injury
median and ulnar nerve –> claw hand, weakness of forearm, dysthesias down medial aspect of arm/hand
associated plexopathy
suprascapular nerve entrapment (purse)
aBduction weakness (1st 15 degrees), shoulder ache
shoulder instability (subluxation) and dislocation
defn and causes
big humeral head –> small articulating surface (glenoid cavity) = instability
get stability from: labrum, which deepens glenoid cavity; rotator cuff tendons; joint capsult & capsular ligaments (thickenings of joint capsule)
inferior capsular (glenohumoral) ligament is most likely to become lax –> anterior dislocation
posterior dislocation requires much more forceful trauma (MVA, seizure)
common causes: weakening of stabilizing structures d/t genes, acute or repetitive trauma, degeneration; prior dislocation = risk factor
shoulder instability and dislocation
dx: clinical presentation and PE findings
instability: asymptomatic, pain, or frequent dislocations
sulcus sign = pull down arm, cavity/subluxation becomes apparent
dislocation: pain, limited rom, possibly visible dislocation, usually +hx trauma
anterior shoulder dislocation
shoulder instability and dislocation
tx and prognosis
pain management
joint reduction
PT to strengthen muscles
good prognosis
complications: neurovascular damage, labral tear, future dislocations
adhesive capsulitis
“frozen shoulder”
scarring and thickening of joint capsule –> limited ROM esp in external rotation
d/t chronic immobility (pain, weakness, stroke, OA, impingingement, prior shoulder surgery)
xray normal, MRI shows scarring
PT, possible corticosteroids, possible surgery
prevention is key, good prognosis if caught early
