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MPT1 > UE - Shoulder Pathology > Flashcards

UE - Shoulder Pathology Flashcards

1
Q

Subjective exam systematic approach

A
  • 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
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2
Q

What are two questions you always ask in subjective exam?

A
  • how old are you?
  • what were you doing when you got hurt?
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3
Q

What is a patient reported outcome measure you can always use?

A

PSFS
Patient specific functional scale
- patient lists three troublesome activities and rates difficulty from 1-10

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4
Q

What is an UE specific patient reported outcome measure?

A

DASH

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5
Q

Objective exam systematic approach

A
  • point to pain
  • clear joints above and below
  • neuro screen
  • observe area (deformity/atrophy)
  • quantity and quality of motion
  • strength assessment
  • special testing
  • palpation
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6
Q

What are three series ordered for shoulder x-rays?

A
  • anteroposterior view (trauma series)
  • scapular “y” lateral view
  • axillary view
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7
Q

anteroposterior x-ray view

A

-neutral, IR, ER
- good view of prox humerus and lateral clavicle, AC joint, upper/lateral scapula

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8
Q

scapular “y” lateral view

A
  • prox humerus fracture or dislocation
  • acromial types - chronic subacromial pain
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9
Q

axillary view

A

“armpit view”
- inferosuperior projection
- GH dislocation, lenoid fossa, coracoid process view

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10
Q

What are three special tests for the cervical region?

A

spurlings, quadrant, and cervical compression

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11
Q

What 3 things does a neuro exam assess?

A

strength, reflexes, sensation

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12
Q

Cervical radiculopathy

A
  • in our scope of practice
  • nerve root issue
  • lower motor neuron signs: hyporeflexia, weakness, bilateral weakness
  • treatments based on relieving inflammation
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13
Q

Cervical myelopathy

A
  • not in scope of practice
  • central cord compression
  • upper motor neuron signs: hyperreflexia, balance impairment
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14
Q

What are the 5 criteria for cervical myelopathy?

A
  • over 45
  • gait ataxia
  • positive inverted supinator test
  • positive hoffmans
  • babinski sign
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15
Q

What are the terminal branches of the brachial plexus and their root levels?

A

M (567)
A (56)
R (56781)
M (56781)
U (81)

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16
Q

What are the two different types of thoracic outlet syndrome?

A
  • neurogenic
  • vascular (arterial or venous)
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17
Q

What are the common sites of compression for thoracic outlet syndrome?

A
  • sternocostovertebral space
  • scalene triangle
  • costoclavicular space
  • coracopectoral space
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18
Q

sternocostovertebral space

A
  • between spine (post), 1st rib (lat), and sternum (ant)
  • where a pancoast tumor would form
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19
Q

scalene triangle

A
  • between ant/mid scalene and clavicle
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20
Q

costoclavicular space

A
  • between clavicle and 1st rib
  • caused by heavy weight on shoulder and shoulder descent (age/posture)
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21
Q

coracopectoral space

A
  • between pec minor and rib cage
  • caused by tight pec minor, overhead activities, anatomic oddness, slouching
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22
Q

What are some special tests for thoracic outlet syndrome?

A

roo’s, adson’s, wright, costoclavicular test

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23
Q

Is vascular or neurogenic more serious?

A

vascular - medical emergency
neurogenic - idea area most likely at fault

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24
Q

What are some treatments for thoracic outlet syndrome?

A
  • inflammation control
  • posture/ergonomic education
  • activity specific biomechanics
  • active rehab (mobility, strength, endurance)
  • TAILOR REHAB FOR SPECIFIC IMPAIRMENTS
  • 1st rib mobilization
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25
Q

Why is the SC joint almost always dislocated from a significant traumatic event?

A
  • significant ligamentous support
  • one of the LEAST DISLOCATED JOINTS
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26
Q

direct sc joint trauma leads to…

A

posterior displacement
can be life threatening

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27
Q

indirect sc joint trauma leads to

A

anterior displacement
- more common, most often from fall on lateral clavicle, can be treated by PT

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28
Q

What are the 3 types of sc sprains?

A

type one - mild sprain, pain with motion
type two - subluxation with movement
type three - dislocation

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29
Q

sc joint sprain treatments

A

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)

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30
Q

_________ % of clavicle fractures are midshaft fractures

A

80

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31
Q

What diagnosis can a midshaft clavicle fracture mimic?

A

AC sprain

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32
Q

nonoperative or surgical treatment of a midshaft clavicle fracture depends on what?

A

amount of shortening (<2cm) and displacement (is it separated too much to make a callus?)

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33
Q

What is our main goal with treating a midshaft clavicle fracture?

A
  • educate our patient
  • restore function
  • prevent nonunion
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34
Q

nondisplaced midshaft clavicle fractures are treated __________

A

nonoperatively

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35
Q

What are the treatment controversies with displaced midshaft clavicle fractures?

A
  • 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
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36
Q

Two ways to get AC joint issues

A
  • atraumatic degenerative changes
  • fall on tucked shoulder “separation”
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37
Q

What are the three ligaments of the AC joint?

A

acromioclavicular
coracoclavicular
coracoacromial

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38
Q

What are the two parts of the CC lig?

A
  • conoid
  • trapezoid (most lateral)
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39
Q

Ways/tests to diagnose AC joint

A
  • chief complaint/body chart
  • plain films
  • diagnostic injection
  • cross arm adduction
  • active compression test
  • paxino test
  • AC shear
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40
Q

3 important rockwood classifications

A

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

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41
Q

Zanca view x-ray

A

useful for seeing cc lig disruption. >50% widening from otherside seen as sprain

42
Q

AC sprain treatment grade 1 and 2

A
  • activity mod/taping
  • short period of immobilization
  • ice/NSAIDs/isometrics/maintain pain free ROM
  • considered manual techniques
43
Q

AC sprain treatment grade 3

A
  • try nonoperative first
44
Q

AC sprain treatment grade 4,5,6

A

surgical eval

45
Q

AC joint arthrosis

A

“hurts”
degenerative change at the AC joint

46
Q

causes of AC joint arthrosis

A
  • related to previous trauma
  • repetitive use
  • may be insidious onset
  • can progress to osteolysis of the joint
47
Q

signs of AC joint arthrosis

A
  • similar pain to AC joint injury
  • no separation deformity
  • inflamed or enlarged AC joint
48
Q

treatment for AC joint arthrosis

A
  • rest and education
  • impairment based rehab
  • injections (diagnostic and theraputic)
  • distal clavicle excision
49
Q

postop considerations of ac joint

A
  • understand purpose of surgery
  • understand def of failure
  • respect sling time
  • progress based on surgeon!
50
Q

Issue with sling usage for AC injury?

A
  • scapula moves inferiorly
51
Q

complications with AC reconstruction

A
  • loss of reduction careful during postop rehab
  • coracoid or clavicular fracture
52
Q

What is the most mobile joint in the body?

A

shoulder

53
Q

great mobility = inherent _________

A

instability

54
Q

static support of shoulder?

A

bone, ligament, labrum

55
Q

dynamic support of shoulder?

A

RC, biceps, delts, pec major, lats

56
Q

What is the primary issue after shoulder dislocation?

A

instability

57
Q

95% of shoulder dislocations are…

A

anterior inferior dislocation

58
Q

common anatomic injuries of dislocated shoulder

A

bankart tear - ant/inf labrum
hill-sachs lesion - posterior humeral head

59
Q

true or false? instability can be measured

A

false, instability is a feeling reported by the patient

60
Q

management of shoulder instability depends on…

A
  • degree of anatomical injury
  • demands of the patient (ex - contact sport)
  • resultant instability versus laxity
61
Q

What ligament is most tight when arm is by your side?

A

superior glenohumeral lig

62
Q

what ligament is tight in the apprehension position?

A

inferior glenohumeral lig
(ant. band - bankart lesion)

63
Q

What predicts poor response to rehab for shoulder instability?

A
  • structural involvement
  • age at first dislocation
  • contact athletes
  • recurrent instability (past injury)
64
Q

TUBS

A

unstable shoulder
T = traumatic
U = unidirectional laxity
B = bankart lesion
S = surgery

65
Q

AMBRI

A

unstable shoulder
A = atraumatic
M = multidirectional laxity
B = bilateral
RI = rehab

66
Q

shoulder subluxation

A

shoulder pops out of socket but goes back in on its own

67
Q

shoulder dislocation

A

joint pops out of socket and requires manual reduction

68
Q

Beighton criteria

A

measures for joint laxity

69
Q

2 types of surgical management for shoulder instability

A
  • soft tissue procedures
  • boney procedures
70
Q

soft tissue procedures for shoulder stability

A
  • bankart repair
  • capsular shift
71
Q

boney procedures for shoulder instability

A
  • 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
72
Q

important things to ask pt with shoulder instability during eval

A
  • 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
73
Q

PT management for shoulder instability

A
  • postop: respect healing time, avoid ABER position
  • nonop. management: rest/protection/prevent recurrence
  • address dynamic stabilizers
  • return to sport considerations
74
Q

How common are posterior shoulder dislocations?

A

2-10%

75
Q

What MOI is most common for posterior shoulder dislocations?

A

FOOSH (flexed, adducted, IR)
contact athletes, cycling, electrocuted, seizures

76
Q

avoid excessive __________ ___________ during rehab for post. shoulder dislocations

A

posterior loading (pushup, planks)

77
Q

What are the Neer stages of impingement for subacromial pain?

A

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

78
Q

What structures are involved in subacromial impingement?

A

restricted space between acromion and HH
bursa, long head of biceps, and surpraspinatus tendon

79
Q

What changes are related to developing subacromial pain?

A
  • acromial shape: type 3 has small link
  • subacromial spurring
  • AC degenerative changes
  • bursal thickening
  • humeral elevation
80
Q

What does a typical patient with subacromial pain look like?

A
  • 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
81
Q

PT plan of care for subacromial pain?

A
  • ACTIVITY MODIFICATION IS A MUST
  • reduce inflammatory response
  • improve glenohumeral rhythm
  • educate patients expectations
82
Q

surgical management of subacromial pain

A
  • diagnostic injection (diagnostic/therapeutic - should be combined with PT)
  • subacromial decompression (debriedment, bursectomy, release CA lig)
  • LH biceps tendonosis
  • AC joint resection
83
Q

Subacromial pain treatment controversy

A

-sham surgery trail (no diff between surgery and control)
- most improve with rehab despite structure
- some improve with no specific treatment

84
Q

Subacromial pain should use a __________ approach for rehab

A

staged

85
Q

Between what 2 structures does shoulder impingement occur?

A

greater tuberosity of HH and posterosuperior aspect of glenoid

  • contact is normal, only pathologic if painful
86
Q

Shoulder impingement GIRD

A

Glenohumeral
Internal
Rotation
Deficit

  • increased ER with repetitive throwing
  • contracture of post band of IGHL
  • increases posterior superior contact
87
Q

Treatment to internal impingement

A
  • posterior capsule stretching
  • addressing SICK scapula and RC strengthening
  • activity modification
88
Q

SICK Scapula

A

Scapular malposition
Inferior medial angle protrusion (winging)
Coracoid pain
K scapular dyskinesia (wing/tip in abnormal ways)

89
Q

SLAP tear

A

superior labral ant/post tear

90
Q

internal impingement clinical presentation

A
  • young overhead athlete
  • post pain with apprehension test
  • GIRD
  • SLAP tears
  • SICK scapula
91
Q

Non-operative treatment for internal impingement

A
  • posterior capsule stretching
  • address SICK scapula, RC strengthening
  • activity modification (remove from play)
92
Q

operative treatment for internal impingement

A
  • articular sided RC tears
  • posterior superior labral tears
  • anterior laxity or instability
  • posterior capsular contracture
93
Q

What are the 3 main functions of RC?

A
  • centers HH in glenoid
  • humeral rotation
  • humeral head depressor
94
Q

Supraspinatus

A
  • suprascapular innervation
  • prone to tears
  • tests: Abd MMT, open can, drop arm, Jobe empty can
95
Q

Infraspinatus

A
  • suprascapular innervation
  • strong ER
  • tests: ERLS, resisted ER with arm at side
96
Q

Teres minor

A
  • axillary innervation
    -ER
  • tests: ERLS, hornblower
97
Q

Subscapularis

A
  • upper/lower subscap innervation
  • IR
  • tests: lift off, belly press, bear hug
98
Q

What is adhesive capsulitis

A
  • capsular inflammation and fibrosis
  • capsular pattern of motion restricted (ER most restricted, AROM and PROM also restricted)
99
Q

What causes adhesive capsulitis

A
  • Diabetes
    -Thyroid disease
  • can occur after injury or surgical scarring
100
Q

How to treat adhesive capsulitis

A
  • joint mobilization
  • pain free resistance training as appropriate
    *-injection therapy with motion exercises
    *- motion exercise and education
101
Q

Is surgery a good way to treat adhesive capsulitis?

A

no!
- hydrodilation: fill capsule with fluid to get inside stretch
- Manipulation under anesthesia then PT
- lysis of adhesions

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