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Orthopedic Diagnostics > Shoulder Pathology > Flashcards

Shoulder Pathology Flashcards

1
Q

The shoulder has ____ degrees of shoulder elevation/rotation. The glenohumeral joint accounts for approximately ____ degrees of this. What supplies the rest of the elevation/rotation?

A

165; 120

The rest is from how the t-spine is extending and the way the scapula is working on the thoracic wall.

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2
Q

Scapular dyskinesis, _____ or winged, can affect actual shoulder _______.

A

tilted, mobility

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3
Q

What is the glenoid labrum? What is it’s function?

A
  • A narrow, wedge-shaped cartilage that deepens the glenoid by 50%.
  • Adds stability yet allows for mobility of the shoulder
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4
Q

Coracoacromial Ligament: Where does it attach? Function?

A

Runs from the coracoid process to the acromion. Forms the roof of the shoulder.

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5
Q

Acromioclavicular ligament: Where does it run? Function?

A

Runs from the acromion to the clavicle. Helps stabilize the clavicle to the scapula.

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6
Q

Coracoclavicular ligaments: What are their names? Where do the run? Function?

A

Trapezoid and conoid ligaments.

Run from the coracoid process to the clavicle.

Help stabilize the clavicle to the scapula.

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7
Q

What are the four bursa of the shoulder?

A
  1. Subacromial
  2. Subdeltoid
  3. Subcoracoid
  4. Subscapular
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8
Q

What are the two bands of the coracohumeral ligament?

A
  1. Anterior (inferior) band
  2. Posterior (superior) band
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9
Q

Where does the anterior (inferior) band of the coracohumeral ligament run?

A

Runs from the coracoid process to the lesser tubercle of the humerus (blends with subscapularis)

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10
Q

What is a test for the anterior (inferior) band of the coracohumeral ligament?

A

Stabilize scapulae and monitor sulcus area with one finger. Take arm in to extension and lateral rotation, distract the humerus and add a traction force via the legs

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11
Q

Where does the posterior (superior) band of the coracohumeral ligament run? What muscle does it blend with?

A

Runs from the coracoid process to the greater tubercle of the humerus (blends with supraspinatus)

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12
Q

How do you test the integrity of the posterior (superior) band of the coracuhumeral ligament?

A

Stabilize scapulae. Take the humerus into flexion, external rotation and adduction, distract the humerus and apply a posterior translation to the GH joint.

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13
Q

Where does the Superior Glenohumeral Ligament run? Function?

A

Runs from the superior aspect of the glenoid (just anterior to the coracoid process) to the lesser tubercle of the humerus.

Function: Primary restraint to inferior translation of an adducted humerus. Think Kettlebell carry or picking up luggage.

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14
Q

Where does the middle glenohumeral ligament run? Function?

A

Runs from the anterior aspect of the glenoid under the SGHL to insert along subscapularis.

Function: Provides anterior stability to the shoulder in 45 degrees of abduction and lateral rotation. Stabilizes in throwing.

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15
Q

Where does the inferior glenohumeral ligament run? Function?

A

Runs from the inferior aspect of the glenoid to insert along the neck of the humerus.

Function: Primary stabilizer of the abducted shoulder. Important stabilizer in dynamic movements.

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16
Q

What is a test for the anterior band of the inferior glenohumeral ligament?

A

Take arm into 90 degrees of abduction and lateral rotation. Apply an anterior translation to the humerus.

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17
Q

What is a test for the pouch of the inferior glenohumeral ligament?

A

Take arm into 90 degrees of abduction and neutral rotation. Apply an inferior translation to the humerus.

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18
Q

What is a test for the posterior band of the inferior glenohumeral ligament?

A

Take arm into 90 degrees of abduction and medial rotation. Apply a posterior translation to the humerus.

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19
Q

What is the rotator cuff in general and what are the muscles involved?

A

Rotator cuff: Intrinsic rotators of the shoulder. Activation of these strengthens the tensile strength of the capsule of the shoulder.

  1. Supraspinatus
  2. Infraspinatus
  3. Teres Minor
  4. Subscapularis
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20
Q

What are the functions of supraspinatus?

A
  • Abductor
  • External rotator at 90 degrees
  • Glenohumeral compression/depressor (humeral head depressor)
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21
Q

What are the functions of infraspinatus?

A
  • External rotator
  • Humeral head depressor
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22
Q

What are the functions of teres minor?

A
  • External rotator
  • Humeral head depressor
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23
Q

What are the functions of subscapularis?

A
  • Internal rotator
  • Humeral head depressor
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24
Q

If the thoracic spine is too stiff or weak how it will affect the rotator cuff?

A

Thoracic spine too weak, rotator cuff strain.

Too stiff in thoracic spine will put rotator cuff at disadvantage

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25
Q

With long head biceps tendinopathy what is the root of the problem usually?

A

Long head biceps tendinopathy: 99% of the time the biceps tendon is the victim, not the problem, it is getting squished or impinged.

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26
Q

Why can supraspinatus aid as a humeral head depressor even with a full thickness tear?

A

Rotator cuff muscles: all humeral head depressors.

Two struts: Subscapularis and infraspinatus together will depress shoulder joint to an extent that it will aid in arm abduction even in the absence of much input from supraspinatus.

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27
Q

The deltoid has anterior, middle and posterior fibers. What are their functions respectively?

A

i. Anterior: Humeral flexor
ii. Middle: Humeral abductor (works with supraspinatus)
iii. Posterior: Humeral extensor

Deltoid will pick up a lot of the slack if rotator cuff is not working properly.

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28
Q

The trapezius has upper, middle and lower fibers. What are their functions respectively?

A

Upper fibers: elevation, works in tandem with serratus anterior to provide upward rotation of scapula during abduction of arm

Middle fibers: retraction of scapula

Lower fibers: depression, works in tandem with serratus anterior to provide upward rotation of scapula during abduction of arm

Note: When activating together, the upper and lower fibers also assist the middle fibers (along with other muscles such as the rhomboids) with scapular retraction/adduction.

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29
Q

Function of rhomboids?

A

Retraction and downward rotation of scapula

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30
Q

Function of levator scapulae?

A

Downward rotation of scapulae

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31
Q

Latissimus dorsi function?

A

Internal rotation, extension and adduction of humerus. It has an influence on the bottom part of the scapula but really just through fascia.

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32
Q

What will happen if pec minor is too tight?

A

Forward tipping of scapula and inferior angle will wing up.

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33
Q

What is the definition of a shoulder labral lesion and what are the two most common types?

A

A shoulder labral lesion involves tearing of the glenoid labrum.

The two types are SLAP and Bankart lesions. Can have variations on these.

34
Q

What are common symptoms of a shoulder labral lesion?

A
  • Loss of strength, feeling of weakness or instability in the shoulder
  • Dull, throbbing, diffuse ache in joint
  • Difficulty sleeping on affected shoulder
  • Popping, clicking and catching sensations or specifically a “clunk”
  • Possible distal symtpoms: numbness, tingling, pain
35
Q

A labral tear can also cause ______. Labral tears often happen in the presence of ______ _____ tears. When one is affected often the other structures are affected even if not damaged.

A

bursitis; rotator cuff

36
Q

What is a SLAP tear?

A

Superior Labrum Anterior Posterior tear

This is a tear of the glenoid labrum, both anteiror and posterior to the attachment of the biceps tendon, often injuring the biceps tendon as well.

Torn from 10 to 2 o’clock position

37
Q

What are specific symptoms of a SLAP tear?

A
  • Any applied force overhead or pushing directly into the shoulder can result in impingement and catching sensation
  • Pain with movement above head or with certain activities such as throwing a ball
38
Q

What are common causes of a SLAP tear?

A
  • FOOSH A fall onto an outstretched arm
  • Forceful pulling on the arm, such as when trying to catch a heavy object
  • Rapid or forceful movement of the arm when it is above the level of the shoulder
  • Repetitive overhead sports, such as throwing athletes or weightlifters.
  • Shoulder dislocation
  • Motor vehicle accident (hands on steering wheel)
39
Q

What are tests for a SLAP tear?

A
  1. Active compression test of O’Brien
  2. Positive apprehension position - relocation test
  3. Crank test (compressive labral rotation test)
40
Q

What does a Bankart lesion entail? What are the two types?

A

Injury of the anterior (inferior) glendoi labrum of the shoulder.

  1. Soft Bankart - injury exclusive to the labrum
  2. Bony Bankart - involves the bony antero-inferior glendoid rim
41
Q

What are specific symptoms of a Bankart lesion?

A
  • Pain gets worse when arm is held behind the back
  • Possible Hill-Sachs lesion: posterolateral humeral head compression fracture as the humeral head comes to rest against the anterio inferior part of the glenoid. May promote future dislocation/subluxation due to lever-like effect of the defect during external rotation.
  • Anything that really forces the shoulder anterior and inferior will aggravate it
42
Q

What are tests for a Bankart lesion?

A
  1. Active Compression Test
  2. Positive Apprehension Position/Relocation test
43
Q

What are conditions you would need to do differential diagnosis for when thinking about a Bankart lesion?

A
  1. Rotator cuff fraying - fraying of tendons where they attach to the bone
  2. Rotator cuff tear - many possible areas for tears including musculotendinous junction, muscle belly, close to bone
  3. Impingement
  4. SLAP lesion - although not always necessary to differentiate between Bankart and SLAP as imaging can be done and that would be up to the doctor. Just identifying a labral tear in general is enough to refer them on.
44
Q

What symptoms differentiate a labral tear from a rotator cuff tear, fraying or impingement?

A
  • Feeling of instability
  • Clunk/shift in shoulder
  • Positive labral tests
45
Q

What are all of the different types of rotator cuff tears?

A
  • Partial tears: 1st-2nd degree, often appear as fraying of an intact tendon.
  • Full thickness tears: 3rd degree, can be…
  1. Small pin point tears.
  2. Larger button hole tears.
  3. Involve the majority of the tendon where the tendon still remains substantially attached to the humeral head.
  4. A complete detachment of the tendon(s) from the humeral head.
46
Q

In an acute traumatic tear of the rotator cuff which area/muscles will usually be affected? What are other symptoms?

A

Traumatic tears predominantly affect the supraspinatus tendon or the rotator interval* and symptoms include severe pain that radiates through the arm, and limited range of motion, specifically during abduction of the shoulder

47
Q

What are the symptoms you would see in a degenerative (chronic and cumulative) rotator cuff tear?

A
  • Atrophy and debilitation of muscles
  • Crackling sensations (crepitus) when moving shoulder
  • Inability to move or lift arm sufficiently, especially during abduction and flexion motions
  • Noticeable pain during rest
  • Sporadic worsening of pain
48
Q

Which muscle has the lowest level of vascularity in the rotator cuff? What does this mean for this muscle?

A

Supraspinatus – lowest level of vascularity, first one to start to degenerate, most commonly involved in tearing

49
Q

How can you differentiate between a shoulder jamming up because of supraspinatus problem or “true jamming” that involves the bones?

A
  • If shoulder is riding high because of supraspinatus problems it may jam up. Note: can still abduct shoulder with tears, it will just be painful. May still be a very functional shoulder.
  • True jamming, shoulder joint abutts the acromion, bony end feel
50
Q

What are risk factors for a rotator cuff tear?

A
  1. Repetitive stress: overhead throwing, rowing, weightlifting and jobs that require frequent shoulder movement.
  2. Impairment of blood supply: increases with age, especially supraspinatus.
  3. Impingement Syndrome: puts shoulder off balance, slightly anterior/superior
51
Q

What tests can be done if you suspect a rotator cuff tear?

A
  1. Check ROM for active abduction, looking for less than 90 degrees
  2. Painful arc
  3. Hawkins Kennedy
  4. Empty can test
  5. Resisted external rotation at 90 degrees of abduction or < 90 degrees abduction
52
Q

If you cannot even get shoulder to 90 degrees __________ is most likely affected

A

Supraspinatus

53
Q

What is the etiology of bursitis?

A

Inflammation of a bursa. Inflammation causes synovial cells to multiply, increasing collagen formation and fluid production within the bursa and reduction in the outside layer of lubrication.

54
Q

What are the causes of bursitis?

A
  • Impact
  • Infection
  • Repetitive trauma/friction: Typically due to micro-trauma to adjacent structures (supraspinatus tendon).
  • Rheumatoid Arthritis: most often systemic, look for infrapatellar bursitis, Achilles tendonitis, etc.
55
Q

What are the symptoms of bursitis?

A
  • Pain with compression of said bursa.
  • Most often presents with a constellation of symptoms called impingement syndrome.
56
Q

What are all the names for impingement syndrome?

A
  • subacromial impingement
  • painful arc syndrome
  • supraspinatus syndrome
  • swimmer’s shoulder
  • thrower’s shoulder.
57
Q

What is the etiology of impingement syndrome?

A

Any decrease in the subacromial space which causes impingement on the structures which pass through this space (supraspinatus tendon, subacromial bursa, long head of biceps tendon)

58
Q

What are the intrinsic factors leading to primary impingement syndrome?

A

Intrinsic factors/Primary Impingement:

a. Subacromial bone spurs
b. Osteoarthritic spurs from the AC joint.
c. Variation in acromial shape
d. Thickening or calcification of coracoacomial ligament

59
Q

What are the extrinsic factors leading to secondary impingment?

A

Extrinsic factors/ Secondary Impingement:

a. Rotator cuff degeneration and weakness – may lead to loss of function of the rotator cuff and subsequent superior translation of the humeral head.
b. Subacromial bursitis
c. Poor posture: anteriorly rolled shoulders (work on strengthening of back, stretching of pecs)
d. Weak scapular stabilizers: Rhomboids, Trapezius (lower fibers)
e. Tight muscles: Pectoralis Major, Minor, Serratus anterior.

60
Q

What are activities that are predisposing factors for impingement syndrome?

A

Overhead activities such as overhead throwing sports, swimming, painting, carpentry, plumbing

61
Q

What are the symptoms of impingement syndrome?

A
  • Arc - painful arc of movement may be present during forward elevation of arm from 60-120 degrees
  • Crepitus
  • Decreased shoulder ROM
  • Decreased shoulder strength with pain.
  • Increase in pain with overhead activities (impingement movements) or lying on shoulder
  • Pain along the front and side of the shoulder.
  • Onset may be sudden if related to trauma or more gradual if related to micro trauma
  • Tenderness on palpation to long head of biceps
62
Q

Differential Diagnosis for Impingement Syndrome

A
  • Rotator cuff pathology (tear): especially if the pain resolves and weakness persists
  • Entrapment of the suprascapular nerve (will see muscle wasting)
  • True impingement – superficial clicking or snapping of tendons over bone or humerus abutting rim of glenoid labrum, not that really deep clunk that you get with a torn labrum
63
Q

What is the painful arc for the glenohumeral joint? What is the subacromial painful arc? General “painful arc”? What if you get pain around 170 degrees?

A

45-120 degrees for GH joint

55-120 degrees for subacromial

60-120 degrees general painful arc

Know for exam: 60-120 degrees to do with shoulder joint, impingement, supraspinatus

If you are getting pain at top around 170, that is AC joint

64
Q

What is the best cohort of tests to diagnose impingement syndrome?

A
  1. Any degree (of) a positive Hawkins-Kennedy test
  2. A positive painful arc sign
  3. Weakness in external rotation with the arm at the side
65
Q

What is the rotator cuff interval (RCI)?

A

A triangular space between the tendons of subscapularis and supraspinatus. A normal rotator cuff interval contains elastic, membranous tissue.

66
Q

What ligaments/structures does the RCI contain?

A
  • Coracohumeral ligament
  • Superior Glenohumeral Ligament
  • Long head of biceps tendon
  • Anterior joint capsule
67
Q

What happens with injury/pathology of the RCI? Mild cases? Severe cases?

A

The RCI becomes thickened, fibrotic and contracted.

  • Mild cases = aggravated or impinged rotator cuff
  • Severe contractures = adhesive capsulitis (frozen shoulder)
68
Q

What is the etiology of an acromioclavicular sprain? What ligaments are involved?

A

Separation of the acromioclavicular joint. Involves injury to the acromioclavicular ligament, occasionally the coracoclavicular ligaments (trapezoid and conoid)

69
Q

What are the causes of an AC sprain (shoulder separation)?

A

i. FOOSH
ii. Fall on elbow
iii. Fall/impact on shoulder

70
Q

What are the symptoms of an AC sprain?

A
  • Tenderness on palpation to the AC joint
  • Pain with cross flexion
  • Step deformity
71
Q

What are the tests for an AC sprain?

A
  1. Cross flexion (with or without elevation)
  2. Compression
72
Q

What are the types of adhesive capsulitis (frozen shoulder)?

A
  1. Idiopathic
  2. Traumatic
  3. Post-surgical
  4. Vaccine related
73
Q

What is the etiology of adhesive capsulitis (frozen shoulder)?

A
  • Synovial fluid decreases
  • Thickening of shoulder capsule
  • Adhesions within the capsule and surrounding connective tissue
74
Q

What is thought to be the cause of frozen shoulder (adhesive capsulitis)?

A

Thought to be caused by injury or trauma to the area and may have an autoimmune component for some.

75
Q

What are risk factors for adhesive capsulitis?

A
  • Connective tissue disease
  • Diabetes mellitus
  • Heart disease
  • Lung disease
  • Stroke
  • Thyroid issues
  • Tonic seizures
76
Q

What are the symptoms of adhesive capsulitis?

A
  • Pain is typically constant
  • Pain intensity increases at night and with cold weather
  • Progressive loss of both active and passive range of motion : capsular pattern (loss of external rotation>abduction>internal rotation)
  • Certain movements or bumps can provoke episodes of tremendous pain and cramping
77
Q

What is stage one of adhesive capsulitis? How should it be treated?

A

The “freezing” or painful stage

  • Lasts from six weeks to nine months
  • Slow onset of pain.
  • Inverse relationship of pain to movement: as the pain increase, shoulder range of motion decreases.

Treatment: Respect pain in first stage. Don’t work through pain but try to maintain range. Anti-inflammatory strategies.

78
Q

Describe stage two of adhesive capsulitis. What is the treatment?

A

The “frozen” or adhesive stage:

  • Lasts from four to nine months.
  • Marked by a slow improvement in pain but the stiffness remains.

Treatment: Physio and deep needling

79
Q

Describe stage three of adhesive capsulitis. What is the treatment?

A

The thawing or recovering phase.

  • Lasts from 5-26 months
  • Shoulder motion slowly returns towards normal.

Treatment: Active rehab.

80
Q

MRI studies of adults who have no shoulder pain show that ___% have partial rotator cuff tears and ___% have full thickness tears.

In addition, in those 60 and older with no shoulder pain or injury, ___% of them had rotator cuff tears on their MRI that they did not even know about .

A study of professional baseball pitchers showed that ___% of them had either partial or full thickness rotator cuff tears yet had no pain while playing and remained pain free even 5 years after the study.

A

20%

15%

50%

40%

81
Q
A

Orthopedic Diagnostics (10 decks)

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