Shoulder Pathos Flashcards
what is the most common MOI for ACJ injuries?
medial/inferior force to the ACJ - football or fall
what is the order of structures injured in an ACJ injury?
AC ligament > CC ligament > delt/trap attachments
what is a type 1 ACJ injury?
AC ligament sprain
CC ligament intact
delt/trap intact
what is a type 2 ACJ injury?
AC ligaments disrupted
CC ligaments sprained
delt/trap intact
what is a type 3 ACJ injury?
AC ligaments disrupted
CC ligaments disrupted (25-100% larger space)
delt/traps detached
what is the major difference between a type 3 and type 4 ACJ injury?
the clavicle is posteriorly displaced in a type 4 injury
what is the major difference between a type 3 and type 5 ACJ injury?
ACJ grossly displaced 100-300% requiring surgery
what is the major difference between a type 3 and a type 6 ACJ injury?
the clavicle is displaced inferiorly
although the most common ACJ MOI is a direct blow, what are three other MOIS?
- FOOSH
- elbow jammed upward
- traction
what are the two sports most commonly associated with ACJ arthrosis
baseball and weightlifting
which three items clue you in to an ACJ pathology?
- MOI
- focal pain at ACJ w radiation proximally
- delt is round, but depressed
what are the four major special tests you should use to dx an ACJ pathology
- o’brien’s active compression
- cross body adduction
- ACJ TTP
- end range painful arc
what three classifications can be made for impingement?
internal, external subacromial, external subcoracoid
describe internal impingement
infra/supraspinatus impinges between labrum/glenoid and greater tuberosity causing tendon fraying and pain
what is the typical patient profile for internal impingement? when does the majority of pain occur?
young overhead throwers during the late cocking phase
what is tight in internal impingement?
posterior IGHL
what is the most common structure of acromion associated with impingement?
type 3 hooked in 70% of cadaveric shoulders
where do we observe external impingement pain in the painful arc test?
60-120 abd > flexion
what is GIRD? who has it?
loss of GH IR due to bone changes, posterior capsule tightness, or RTC tightness
throwing athletes
What is the CPG to rule in shoulder pain from muscle power deficits? (4)
- symptoms worsen with repetitive overhead mvmts
- midrange catching
- midrange resistance flx/abd pain
- weak RTC
what is the CPG to rule out shoulder pain from muscle power deficits? (4)
- resistive tests pain-free
- supra/infra/biceps normal strength
- loss of PROM
define multidirectional instability of the GHJ
MDI: symptomatic laxity in two or more directions, one of which is always inferior
differentiate between laxity and instability
laxity - extent to which the humeral head can be translated on the glenoid
instability - abnormal increase in GH translation causing symptoms related to sublux/dislocation
what are the two classifications of instability?
AMBRI and TUBS
what is AMBRI
atraumatic, multidirectional, bilateral, rehab effective, inferior capsule shift
what is TUBS
traumatic dislocation, unidirectional, bankhart, surgery
what is the most common pathology seen in anterior shoulder dislocations?
bankart lesion
what is a bankart lesion?
(aka Perthes lesion) avulsion of the glenoid labrum in the anterior inferior quadrant
what is are typical MOIs for Bankart lesions?
QB blocked throw, blocked dunk (abd, ext, ER)
what is a hill-sachs lesion? what causes it?
compression fx of the post/lat humeral head occuring over time with anterior dislocations
what do you find on examination of an anterior dislocation?
- FLATTENED DELTOID
- increased acromial prominence
- arm in a protected position, acute
during a fx or complete tear (severe trauma) which nerve are we worried about and what does it supply
axillary - deltoid and teres minor
in what pt demographic are recurrence rates of anterior dislocation highest? (90%)
< 20 after traumatic dislocation
what exam findings do you expect in this patient?
- ER < 0
- elevation < 90
- IR and horiz add cause pain
what causes posterior dislocations? what two anatomical changes can occur?
FOOSH; reverse bankhart and reverse hill sachs
what is a type 1 SLAP tear
labral degeneration (frayed edges), but no avulsion
what is a type 2 slap tear?
most commonly reported - complete labral detachment from ant/sup to post sup, thus causing biceps tendon instability
what is a type 3 SLAP tear?
bucket handle displacement of labrum into the joint, BUT no instability of the biceps tendon
what is a type 4 SLAP lesion?
similar to type 3 but the labrum AND biceps tendon are detached
what is the CPG for ruling IN shoulder instability? (5)
- <40
- hx of dislocations
- excessive GHJ accessory motion in multiple planes
- apprehension at endrange
- deep ache intermittant pain (w or without click) worse with overhead
what is the CPG to rule OUT shoulder instability
- no hx of dislocation
- globally limited ROM
- no apprehension
how do you identify scapular dyskinesis
SICK for overhead athletes
S: scap malposition
I: inferior medial border prominent
C: coracoid pain
K: dysKinesis
how does kibler classify scap diskinesis?
type 1 = inferior
type 2 = medial
type 3 = superior
named after whats visually prominent
an inferior angle will become more prominent with which position cue?
hands on hips
which muscle are weak in type 1 scap dyskinesis
LT, lats, SA
which muscles are weak in type 2 scap dyskinesis?
rhomboids, all traps, and SA
describe kiblers scap assistance test
for PAINFUL type 1 scap dyskinesis, stabilizing the inferior angle of the scap during movement will decrease pain
describe kiblers scap retraction test
for PAINFUL type 2 scap dyskinesis, positive if stablizing the medial border during motion decreases pain
what is flip sign?
resisted ER protrustion of scap signalling weak infraspin and teres minor
what three things cause frozen shoulder?
- stiffening capsule, lig, tendon
- adhesions along RTC surface
- adhesions in biceps tendon
what is the profile for frozen shoulder?
- 40-65 years
- female
- minor injuries
- non-shoulder surgeries
- immobility
- systemic diseases (esp diabetes)
how long does frozen shoulder last?
self-limiting 1-3 years but mob deficits up to 10 years
what is the recurrence for frozen shoulder? unilateral or bilateral?
recurrence and bilateral rare
what are the three stages of frozen shoulder?
- painful freezing
- frozen
- thawing
decribe stage 1 frozen shoulder
3-9 months
- severe pain esp lying on side
- sleep problems
- absence of PROM limitation
- synovitis upon arthroscopy
describe stage 2 frozen shoulder
4-12 months
- pain gradually diminishes
- stiffness increases
- PROM limited in all directions by 50% (ER most)
- capsule hypertrophy/CHL contracture
describe stage 3 frozen shoulder
12-42 months
- pain beginning to resolve
- persistent but resolving stiffness
which three systemic diseases are majorly implicated in frozen shoulder
- diabeetus
- thyroid disease
- autoimmune diseases
what are the CPG criteria to rule in frozen shoulder?
- 45-60 years
- gradual onset of pain and stiffness
- PROM limited in multiple directions (esp ER)
- ER/IR decreases at 90 GH abd
what are the CPG criteria to rule out frozen shoudler
- PROM normal
- ER/IR increases at 90 abd
- TTP
- ULTT repro of sxs
how do you manage highly irritable frozen shoulder pts (4)
- heat/stim for pain
- positioning and act mods
- easy mobs
- pain free PROM to induce synovium mvmt
how do you manage moderately irritable frozen shoulder patients
same as for irritable but mobilize to R1
how do you manage nonirritable frozen shoulder pts
work em!
- high amplitude and long duration mobs
- stretching to pain tolerance
which three outcomes would you use for frozen shoulder
- DASH
- SPADI (shoulder pain and disability)
- ASES (american shoulder and elbow surgeons)
where can the suprascapular nerve impinge? profile?
supraspinous fossa/suprascap notch
45% volleyball players or RTC full thickness tears
how would you describe suprascapular nerve pain and what would be the major objective finding?
vague, dull, burning, diffuse ache posterolaterally; painless weakness to resisted abduction/ER
what causes a spinal accessory nerve injury and what muscles can it affect?
stretch/whiplash, compression from backpack, lymph node surgery
SCM and UT
what causes Parsonage Turner Syndrome (LTN injury) and what muscle does it affect?
prolonged arm traction with head turned away; SA
quadrilateral space syndrome - low yield
humerus shaft, long head triceps, teres minor, teres major
contents: axillary n and post humeral circumflex artery
dead arm/vague pain and weakness overhead
