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MSK I > Shoulder Pathology > Flashcards

Shoulder Pathology Flashcards

1
Q

Rotator cuff dynamically stabilizes the glenohumeral joint

A

Reduces stress on ligaments

Compresses humeral head into glenoid

Works as a unit, not individually

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2
Q

Scapula

A

Moves with humerus to maintain length tension relationships

Provide a stable base for GH mobility

Proximal stability promotes distal mobility

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3
Q

Sub-acromial pain:

A

pain associated with structures of the subacromial space (AKA impingement syndrome)

commonly injured = supraspinatus, bursae, biceps LH

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4
Q

RCD:

A

continuum from tendinopathy through full thickness tear

begins with acute inflammation -> small partial tear -> full thickness tear -> unattached

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5
Q

How Does RCD Develop?

A

Traumatic Rotator Cuff Tears are much less common than Chronic Rotator Cuff Tears

There are 2 predominant theories in how RCD progresses:
Impingement Model VS Tendon Degeneration Model

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6
Q

Impingement

A

Pain originating from structures in the subacromial space (cuff, bursa, LHB)

Purposely vague
> Allows for uncertainty
> Allows for multiple mechanisms

sub-acromial structures come through, tendon becomes irritated, no inferior GH head rotation when elevation, leads to pinching until rupture over time

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7
Q

Sub-acromial Pain Syndrome

(this is what we are moving toward)

A

Impingement of the sub-acromial structures

Limited evidence of compression mechanism

Perpetuates flawed mechanism and therefore flawed treatment decisions

Multiple trials have found acromioplasty did not prevent tears or reduce pain

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8
Q

Tendon Degeneration Model

A

tendon becomes overloaded = poor blood supply and metabolism = can’t keep up with normal healing = everywhere else in the body follows this except the shoulder

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9
Q

Sub-acromial decompression:

latest of the most common performed surgeries - lack of evidence to prove its doing what its supposed to be doing = being seen less and less

A

Shave off undersurface of acromion/coracoacromial arch to increase sub-acromial space

Doesn’t prevent RCD progression

Does not show improved outcomes over rehab alone or compared to placebo

Despite evidence, still commonly performed surgery

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10
Q

Our evidence does not support impingement as a primary driver of RCD

A

Subacromial space impingement occurs in everyone

The supraspinatus tendon is not available to be impinged upon through the ROM where people are typically symptomatic

Surgeries to correct impingement do not improve outcomes over rehab and do not prevent future rotator cuff tears

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11
Q

Impingement has been replaced by subacromial pain/rotator cuff related pain

A

Impingement perpetuates a flawed mechanism which can perpetuate flawed treatments:
> tendon inflammation and degeneration
> sub acromial space gets smaller in everyone (impinges when we lift arm)
> not only happening in symptomatic people
> supraspinatus is not able to be impinged upon during the “painful” range

SAP still a vague term

need to “train” scapula in retracted inferior position to open more room in subacromial space = not true

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12
Q

Tendon degeneration model is accepted for all the other joints. Why not shoulder?

A

shoulder joint is highly mobile =wide ROM compared to other joints = places different demands on the tendons and muscles surrounding the shoulder, potentially leading to different mechanisms of injury or degeneration

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13
Q

Most common reason for shoulder pain (no definable tears)

A

Rotator Cuff Disease/ Sub-Acromial Pain

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14
Q

Rotator Cuff Disease/ Sub-Acromial Pain
Key findings:

A

Painful Arc

Palpation to differentiate biceps vs cuff

Will not have substantial shoulder weakness

Will not have instability signs

Positive SAP tests

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15
Q

Rotator Cuff Disease/ Sub-Acromial Pain
Common Impairments (assess don’t assume)

A

Minor loss of motion, Reverse

Thoracic spine stiffness

Tight pec minor/ posterior shoulder

Weak Scapular Muscles

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16
Q

Rotator Cuff Disease/ Sub-Acromial Pain
Medical Management

A

Oral steroids or NSAIDs
Injections
Surgery

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17
Q

Injections

A

Steroid with lidocaine into sub-acromial space (cortisone, Kenalog)

Used sparingly due to association of steroid injections and tendon rupture

Purpose is to reduce pain in conjunction with rehab

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18
Q

Surgery

A

Sub-acromial decompression/acromioplasty

Debridement

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19
Q

Secondary “Impingement”
Occurs due to:

A

Laxity
Muscle imbalances
Capsular/soft tissue imbalances

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20
Q

Rotator Cuff Tears

A

Partial or full thickness

Bursal = superior surface

Articular = inferior portion of tendon

Mid-substance = partial tears

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21
Q

Rotator Cuff Tears
Key Findings:

A

Positive Drop arm, ER weakness

Possible substantial loss of ROM and/or MMT

Negative Instability

22
Q

Rotator Cuff Tears
Common Impairments:

A

Significant weakness
Otherwise same as SAP

23
Q

Rotator Cuff Tears
Size classification (by longest diameter):

A

small <1cm
medium <3cm
large <5cm
massive >5, usually retracts

24
Q

Degenerative cuff tears thought to be a normal aging process

A

30% in age 40+
80% in age 60+

Can commonly be asymptomatic
Unclear how a tear becomes symptomatic

25
Q

Rotator Cuff Tears
Diagnosis:

A

MRI – gold standard

Ultrasound- just as good as MRI, much cheaper, no contraindications for metal implants or claustrophobia

Correlation of imaging to physical exam

26
Q

Does the Tear Progress?

A

WE DON’T KNOW

can’t tell who’s who before

won’t know who will get better or worse

27
Q

Rotator Cuff Tears
Medical Management

A

Injections/Oral Steroids

Surgery
> Repair at enthesis = Use suture anchors to hold the tendon back onto its insertion site (bone)

> Debridement (helps symptoms)

28
Q

Loose Shoulder Conditions

A

Traumatic Instability
Multi-directional Instability
Labral Tears

29
Q

TUBS

A

Traumatic (humeral head forced out, dislocation)
Unilateral (one side)
Bankart
Surgery (treatment)

(greater instability)

30
Q

AMBRI

A

Atraumatic
Multidirectional
Bilateral
Rehab
Inferior Capsular Shift

(a million surgeries, none work) (super lax people that get injured)
(poor neuromuscular control)

31
Q

Unidirectional Instability

A

Dislocation = out of joint

Subluxation= not fully out

90% Anterior or Ant/Inf

Young Men, Collision Sports

FOOSH, High 5 Position, Horiz Abd

Diagnosis = radiographs

32
Q

Shoulder Instability
Pathology:

A

Bankart Lesion- Avulsion of labrum from glenoid

Boney Bankart- Avulsion of labrum that pulls off a piece of glenoid

Hills-Sachs- Posterior humeral head compression fx

Watch for neurovascular bundle injury

Suspect rotator cuff tear with dislocations over 40 = Despite an episode of instability, concern is stiffness

33
Q

Shoulder Instability
Outcomes:

A

High recurrence rate without surgery: 60-90% in high risk population, less in general population

Repeated dislocations -> anterior glenoid bone loss -> Lartarjet

40% OA 10-15 yrs

34
Q

Shoulder Instability
Important subjective info:

A

Chronicity
Frequency
Voluntary/involuntary

35
Q

Shoulder Instability
Medical Management:

A

Surgery:

Bankart Repair with/without capsule plication
> open = less common
> arthroscopic = gold standard - less trauma to other tissues

Latrajet

36
Q

Shoulder Instability
Multi-Directional:

A

Young females, generalized laxity (beighton score)

Usually atraumatic, sublux/dislocates with low risk activity (ADL’s, sleep, etc)

Rehab is gold standard, avoid surgical procedures if possible as they tend to have poor outcomes

Surrounding musculature highly irritated from trying its best to provide dynamic stability

Paresthesia

37
Q

Microtrauma Instability:

A

Throwers/overhead athletes/swimmers

Stretch out capsule

Repetitive microtrauma

38
Q

Labral Tears

A

Anterior/Inferior = Commonly occur with instability (88-100%)

Posterior = Commonly occur with instability

Superior (SLAP) = Under 40 commonly occur with instability, Over 40 more degenerative

39
Q

Labral Tears
Diagnosis:

A

Primarily made on history, as special tests are poor and clinical exam can mimic instability/SAP

Traditional MRI unreliable

Need MR Arthrogram
> MRI + Dye injected into joint
> If dye leaks out = likely labral tear

40
Q

Anterior/Inferior tear -

A

> Deep anterolateral pain

> Usually hurts more after use as opposed to during

> Can tear labrum or avulse from glenoid

> Same MOI as anterior dislocations

41
Q

Posterior tear =

A

> Deep pain, posterolateral

> Usually hurts more after use as opposed to during

> Reverse bankart

> Same MOI as post dislocations (horiz add and posterior force)

42
Q

SLAP tear =

A

MOI
> Traction
> Repetitive biceps contraction (overhead)
> Compressed loading in flex/abd

Type 2 most common (40%)

Degenerative if 40+ (no surgery)

43
Q

Labral Tears
Medical Management

A

Injections

Surgery
> Labral repair
> Debridement

44
Q

Stiff Shoulder Conditions

A

Adhesive Capsulitis
Osteoarthritis

<80% contralateral side is considered overly stiff

45
Q

Adhesive Capsulitis

A

Unknown etiology

Unknown pathophysiology

Inflammation and resultant fibrosis

70% females, 40+ yrs, diabetics

Traumatic or atraumatic

Capsular pattern

Difficult to diagnose early as it mimics SAP

Can take 1-2 yrs to resolve
(some don’t get all ROM back)

Stages of recovery are not supported by evidence

Irritability is a better guide

MRI can spot disease process

46
Q

MUA
LOA

A

MUA - moving away from this

LOA = usually bolus PT directly after

47
Q

Osteoarthritis

A

Rarely symptomatic if < 45 yrs

Pain and progressive functional limitations

Capsular pattern

Promote movement without aggravating synovitis

48
Q

Joint Arthroplasty

A

gets rid of pain

TSA if healthy cuff

Reverse TSA if cuff is not healthy

49
Q

Proximal humeral fractures

A

Occur with falls or pathologically

Usually occur at surgical neck

+/- Cuff Tear

Treatment:
> Protection
> ORIF (open reduction internal fixation)

50
Q

AC Joint Injuries

A

Fairly common, “separation”

MOI: fall or contact on point of shoulder

Usually treated with brace and PT

Worse at end range elevation and horiz add

51
Q

Treatment for AC injuries

A

sling/brace
> ligament stretched
> partial rupture AC ligaments
> complete rupture AC and CC ligaments

surgery
> clavicle displaced posterior over acromion
> clavicle displaced under skin
> clavicle underneath coracoid (rare)

MSK I (9 decks)

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