UE - Shoulder Pathology Flashcards
Subjective exam systematic approach
- how old are you?
- what were you doing at onset?
- what is your chief complaint
- aggravating/easing factors?
- radiating or radicular complaints
- patient reported outcome measures
- develop differential diagnoses
- body chart
What are two questions you always ask in subjective exam?
- how old are you?
- what were you doing when you got hurt?
What is a patient reported outcome measure you can always use?
PSFS
Patient specific functional scale
- patient lists three troublesome activities and rates difficulty from 1-10
What is an UE specific patient reported outcome measure?
DASH
Objective exam systematic approach
- point to pain
- clear joints above and below
- neuro screen
- observe area (deformity/atrophy)
- quantity and quality of motion
- strength assessment
- special testing
- palpation
What are three series ordered for shoulder x-rays?
- anteroposterior view (trauma series)
- scapular “y” lateral view
- axillary view
anteroposterior x-ray view
-neutral, IR, ER
- good view of prox humerus and lateral clavicle, AC joint, upper/lateral scapula
scapular “y” lateral view
- prox humerus fracture or dislocation
- acromial types - chronic subacromial pain
axillary view
“armpit view”
- inferosuperior projection
- GH dislocation, lenoid fossa, coracoid process view
What are three special tests for the cervical region?
spurlings, quadrant, and cervical compression
What 3 things does a neuro exam assess?
strength, reflexes, sensation
Cervical radiculopathy
- in our scope of practice
- nerve root issue
- lower motor neuron signs: hyporeflexia, weakness, bilateral weakness
- treatments based on relieving inflammation
Cervical myelopathy
- not in scope of practice
- central cord compression
- upper motor neuron signs: hyperreflexia, balance impairment
What are the 5 criteria for cervical myelopathy?
- over 45
- gait ataxia
- positive inverted supinator test
- positive hoffmans
- babinski sign
What are the terminal branches of the brachial plexus and their root levels?
M (567)
A (56)
R (56781)
M (56781)
U (81)
What are the two different types of thoracic outlet syndrome?
- neurogenic
- vascular (arterial or venous)
What are the common sites of compression for thoracic outlet syndrome?
- sternocostovertebral space
- scalene triangle
- costoclavicular space
- coracopectoral space
sternocostovertebral space
- between spine (post), 1st rib (lat), and sternum (ant)
- where a pancoast tumor would form
scalene triangle
- between ant/mid scalene and clavicle
costoclavicular space
- between clavicle and 1st rib
- caused by heavy weight on shoulder and shoulder descent (age/posture)
coracopectoral space
- between pec minor and rib cage
- caused by tight pec minor, overhead activities, anatomic oddness, slouching
What are some special tests for thoracic outlet syndrome?
roo’s, adson’s, wright, costoclavicular test
Is vascular or neurogenic more serious?
vascular - medical emergency
neurogenic - idea area most likely at fault
What are some treatments for thoracic outlet syndrome?
- inflammation control
- posture/ergonomic education
- activity specific biomechanics
- active rehab (mobility, strength, endurance)
- TAILOR REHAB FOR SPECIFIC IMPAIRMENTS
- 1st rib mobilization
Why is the SC joint almost always dislocated from a significant traumatic event?
- significant ligamentous support
- one of the LEAST DISLOCATED JOINTS
direct sc joint trauma leads to…
posterior displacement
can be life threatening
indirect sc joint trauma leads to
anterior displacement
- more common, most often from fall on lateral clavicle, can be treated by PT
What are the 3 types of sc sprains?
type one - mild sprain, pain with motion
type two - subluxation with movement
type three - dislocation
sc joint sprain treatments
type three - send to ER
otherwise:
- reduce inflammation (activity mod, short immobilization, ice)
- reduced motion, strength, endurance
- consider SC joint mobilization
- return to sport considerations (depends on sport)
_________ % of clavicle fractures are midshaft fractures
80
What diagnosis can a midshaft clavicle fracture mimic?
AC sprain
nonoperative or surgical treatment of a midshaft clavicle fracture depends on what?
amount of shortening (<2cm) and displacement (is it separated too much to make a callus?)
What is our main goal with treating a midshaft clavicle fracture?
- educate our patient
- restore function
- prevent nonunion
nondisplaced midshaft clavicle fractures are treated __________
nonoperatively
What are the treatment controversies with displaced midshaft clavicle fractures?
- treatment preference based on provider seen
- rate of malunion or nonunion
- excessive shortening of the clavicle
- return to sport timeframe
- surgery comes with risk of complication
- slight increased risk of nonunion without surgery
Two ways to get AC joint issues
- atraumatic degenerative changes
- fall on tucked shoulder “separation”
What are the three ligaments of the AC joint?
acromioclavicular
coracoclavicular
coracoacromial
What are the two parts of the CC lig?
- conoid
- trapezoid (most lateral)
Ways/tests to diagnose AC joint
- chief complaint/body chart
- plain films
- diagnostic injection
- cross arm adduction
- active compression test
- paxino test
- AC shear
3 important rockwood classifications
degree and direction of shoulder displacement:
type 1- mild AC sprain
type 2 - tear AC lig
type 3 - tear AC and CC lig/sup clavicle displacement
Zanca view x-ray
useful for seeing cc lig disruption. >50% widening from otherside seen as sprain
AC sprain treatment grade 1 and 2
- activity mod/taping
- short period of immobilization
- ice/NSAIDs/isometrics/maintain pain free ROM
- considered manual techniques
AC sprain treatment grade 3
- try nonoperative first
AC sprain treatment grade 4,5,6
surgical eval
AC joint arthrosis
“hurts”
degenerative change at the AC joint
causes of AC joint arthrosis
- related to previous trauma
- repetitive use
- may be insidious onset
- can progress to osteolysis of the joint
signs of AC joint arthrosis
- similar pain to AC joint injury
- no separation deformity
- inflamed or enlarged AC joint
treatment for AC joint arthrosis
- rest and education
- impairment based rehab
- injections (diagnostic and theraputic)
- distal clavicle excision
postop considerations of ac joint
- understand purpose of surgery
- understand def of failure
- respect sling time
- progress based on surgeon!
Issue with sling usage for AC injury?
- scapula moves inferiorly
complications with AC reconstruction
- loss of reduction careful during postop rehab
- coracoid or clavicular fracture
What is the most mobile joint in the body?
shoulder
great mobility = inherent _________
instability
static support of shoulder?
bone, ligament, labrum
dynamic support of shoulder?
RC, biceps, delts, pec major, lats
What is the primary issue after shoulder dislocation?
instability
95% of shoulder dislocations are…
anterior inferior dislocation
common anatomic injuries of dislocated shoulder
bankart tear - ant/inf labrum
hill-sachs lesion - posterior humeral head
true or false? instability can be measured
false, instability is a feeling reported by the patient
management of shoulder instability depends on…
- degree of anatomical injury
- demands of the patient (ex - contact sport)
- resultant instability versus laxity
What ligament is most tight when arm is by your side?
superior glenohumeral lig
what ligament is tight in the apprehension position?
inferior glenohumeral lig
(ant. band - bankart lesion)
What predicts poor response to rehab for shoulder instability?
- structural involvement
- age at first dislocation
- contact athletes
- recurrent instability (past injury)
TUBS
unstable shoulder
T = traumatic
U = unidirectional laxity
B = bankart lesion
S = surgery
AMBRI
unstable shoulder
A = atraumatic
M = multidirectional laxity
B = bilateral
RI = rehab
shoulder subluxation
shoulder pops out of socket but goes back in on its own
shoulder dislocation
joint pops out of socket and requires manual reduction
Beighton criteria
measures for joint laxity
2 types of surgical management for shoulder instability
- soft tissue procedures
- boney procedures
soft tissue procedures for shoulder stability
- bankart repair
- capsular shift
boney procedures for shoulder instability
- indicated for significant bone loss
- recurrence after soft tissue procedures
- latarjet - coracoid transfer
- remplissage for engaging hill-sachs lesions
- allograft for large hill-saches lesion
important things to ask pt with shoulder instability during eval
- age, onset, gender, sport, position
- number of instability events
- subluxation vs dislocation
- initial treatment to date/imaging?
- axillary nerve commonly impaired
- apprehension and relocation test
- sulcus sign - SGHL, inf. instability
- patient goals
PT management for shoulder instability
- postop: respect healing time, avoid ABER position
- nonop. management: rest/protection/prevent recurrence
- address dynamic stabilizers
- return to sport considerations
How common are posterior shoulder dislocations?
2-10%
What MOI is most common for posterior shoulder dislocations?
FOOSH (flexed, adducted, IR)
contact athletes, cycling, electrocuted, seizures
avoid excessive __________ ___________ during rehab for post. shoulder dislocations
posterior loading (pushup, planks)
What are the Neer stages of impingement for subacromial pain?
stage 1 - young, no tears or surgery
stage 2 - 25-40, scarring may require subacromial decompression
stage 3 - over 40, may have RC tear, may need RC repair
What structures are involved in subacromial impingement?
restricted space between acromion and HH
bursa, long head of biceps, and surpraspinatus tendon
What changes are related to developing subacromial pain?
- acromial shape: type 3 has small link
- subacromial spurring
- AC degenerative changes
- bursal thickening
- humeral elevation
What does a typical patient with subacromial pain look like?
- over 40
- general atraumatic shoulder pain
- painful arc of elevation 60-160
- point to lateral arm/middle delt for pain
- must rule out RC tear first
- must rule out impingement tests
- then exam AC joint
- then examen biceps tendon
PT plan of care for subacromial pain?
- ACTIVITY MODIFICATION IS A MUST
- reduce inflammatory response
- improve glenohumeral rhythm
- educate patients expectations
surgical management of subacromial pain
- diagnostic injection (diagnostic/therapeutic - should be combined with PT)
- subacromial decompression (debriedment, bursectomy, release CA lig)
- LH biceps tendonosis
- AC joint resection
Subacromial pain treatment controversy
-sham surgery trail (no diff between surgery and control)
- most improve with rehab despite structure
- some improve with no specific treatment
Subacromial pain should use a __________ approach for rehab
staged
Between what 2 structures does shoulder impingement occur?
greater tuberosity of HH and posterosuperior aspect of glenoid
- contact is normal, only pathologic if painful
Shoulder impingement GIRD
Glenohumeral
Internal
Rotation
Deficit
- increased ER with repetitive throwing
- contracture of post band of IGHL
- increases posterior superior contact
Treatment to internal impingement
- posterior capsule stretching
- addressing SICK scapula and RC strengthening
- activity modification
SICK Scapula
Scapular malposition
Inferior medial angle protrusion (winging)
Coracoid pain
K scapular dyskinesia (wing/tip in abnormal ways)
SLAP tear
superior labral ant/post tear
internal impingement clinical presentation
- young overhead athlete
- post pain with apprehension test
- GIRD
- SLAP tears
- SICK scapula
Non-operative treatment for internal impingement
- posterior capsule stretching
- address SICK scapula, RC strengthening
- activity modification (remove from play)
operative treatment for internal impingement
- articular sided RC tears
- posterior superior labral tears
- anterior laxity or instability
- posterior capsular contracture
What are the 3 main functions of RC?
- centers HH in glenoid
- humeral rotation
- humeral head depressor
Supraspinatus
- suprascapular innervation
- prone to tears
- tests: Abd MMT, open can, drop arm, Jobe empty can
Infraspinatus
- suprascapular innervation
- strong ER
- tests: ERLS, resisted ER with arm at side
Teres minor
- axillary innervation
-ER - tests: ERLS, hornblower
Subscapularis
- upper/lower subscap innervation
- IR
- tests: lift off, belly press, bear hug
What is adhesive capsulitis
- capsular inflammation and fibrosis
- capsular pattern of motion restricted (ER most restricted, AROM and PROM also restricted)
What causes adhesive capsulitis
- Diabetes
-Thyroid disease - can occur after injury or surgical scarring
How to treat adhesive capsulitis
- joint mobilization
- pain free resistance training as appropriate
*-injection therapy with motion exercises
*- motion exercise and education
Is surgery a good way to treat adhesive capsulitis?
no!
- hydrodilation: fill capsule with fluid to get inside stretch
- Manipulation under anesthesia then PT
- lysis of adhesions
