Week 4- Shoulder Flashcards
1
Q
shoulder pain is the ___ most common MSK problem
A
3rd
2
Q
most shoulder problems are extrinsic or intrinsic
A
intrinsic
3
Q
extrinsic causes of shoulder pain
A
Extrinsic Causes involving neurologic disorders or visceral conditions may refer pain to the shoulder. Cervical spine disease is the most common cause of referred pain to the shoulder.
4
Q
most common extrinsic cause of shoulder pain
A
cervical spine disease
5
Q
intrinsic causes of shoulder pain increase with ___
A
intrinsic causes the shoulder pain should increase with shoulder and arm movement.
6
Q
examples of extrinsic causes of shoulder pain
A
gallbladder, thoracic, cervical
7
Q
intrinsic causes
A
trauma, fracture, dislocation???
8
Q
if pain only on AROM what is involved
A
pain occurs with only active range of motion (which stresses the muscles, tendons, and ligaments)
soft tissue disorders such as rotator cuff or biceps tendonitis, rotator cuff tendinopathy/tears, or subacromial bursitis.
9
Q
pain with AROM and PROM
A
Pain with active and passive motions suggests involvement of the glenohumeral joint (eg, osteoarthritis, frozen shoulder, gout, osteonecrosis) or AC joint disease (eg, separation or osteoarthritis).
10
Q
pain with elevation of arm above head
A
impingement syndrome
11
Q
pain with lifting items with biceps or wrist supination
A
biceps tendinitis
12
Q
what intrinsic cause has 50-90% prevalence?? most common
A
Impingement syndrome/rotator cuff tendinitis(includes full and partial rotator cuff tears)
13
Q
intrinsic causes of shoulder pain
A
- Impingement syndrome/rotator cuff tendinitis(includes full and partial rotator cuff tears): 48%-85% prevalence
- Calcific tendinitis: 6% prevalence
- Biceps tendinitis/long head
- Glenohumeral instability
- Acromioclavicular syndromes
- Frozen shoulder/capsulitis: 16%-22% prevalence
- Glenoid labrum tear
- Inflammatory arthritides including rheumatoid, crystal associated, reactive etc.
- Infection of joint or soft tissues
- Osteoarthritis
- Polymyalgia rheumatica
- Osteonecrosis
14
Q
chest disorders as extrinsic cause of shoulder pain
A
- Myocardial infarction
- Angina pectoris
- Pericarditis
- Aortic dissection
- Pulmonary embolism
- Pneumothorax
- Pneumonia
- Pleuritis
- Pancoast tumour
- Mesothelioma
- Mediastinal or lung neoplasm
15
Q
abdominal disorders as extrinsic causes of shoulder pain (left and right shoulder)
A
Left shoulder pain:
* Splenic infarction
* Splenic rupture
Right shoulder pain
* Hepatic abscess
* Cholecystitis
* Hepatic hematoma
Left and/or right shoulder pain:
* Subphrenic abscess
* Intra-abdominal hemorrhage
* Ruptured abdominal viscus
16
Q
neurological disorders as causes of extrinsic shoulder pain
A
- Cervical radiculopathy
- Brachial plexopathy
- Entrapment neuropathy
- Herpes zoster
- Cervical spinal stenosis
- Thoracic outlet syndrome
17
Q
esophageal diseases as causes of extrinsic shoulder pain
A
- Aneurysm
- Peptic ulcer
- Pancreatitis
- Abdominal neoplasms
- Ectopic pregnancy
18
Q
vascular insufficiency as cause of extrinsic shoulder pain
A
- Arteritis
- Venous thrombosis
19
Q
extrinsic shoulder pain is unaffected by
A
motion of arm
20
Q
rotator cuff disease
A
consists of tendinopathy of one or more of the four rotator cuff muscles, full- or partial-thickness tears of these rotator cuff tendons, or bursitis of the sub acromial bursa.
refers to a range of conditions affecting the rotator cuff, a group of muscles and tendons that stabilize the shoulder joint and allow for its movement. Common issues include tendinitis, tears, and impingement.
21
Q
tendinopathy vs tendonitis
A
tendinopathy= degeneration of collagen
tendonitis= inflammation
22
Q
asymptomatic shoulders can still have problems??
A
One study of asymptomatic shoulders detailed that partial rotator cuff tears were present in 20% of the population, and 15% had full-thickness tearing.
23
Q
tendinopatjhy from receptive contact of tendons with movement between
A
the acromioclavicular arch and the humeral head and between the joint capsule and the glenoid rim.
24
Q
initial inflammatory changes in tendinopathy
progress to
A
seen on imaging as peritendinitis and focal thickness
progress to mucoid degeneration, chondral metaplasia, and amyloid deposition. an increase of fibroblastic cells and neovascularization
=== degenerative tendinoatpthy
25
what is the precursor to tendon tears
degenerative tendinopathy
26
what Is needed to confirm a tear
MRI or ultrasound
27
what physical test is commonly associated with complete tear
drop arm test
28
burial side tears have a tcendedncy to heal becaseu
blood supply
Bursal-side tears are associated with subacromial and coracohumeral arch degenerative changes. Because of their adequate blood supply, they have a tendency to heal.
29
most common type of tear
partial articular surface tears
PASTA (partial articular supraspinatus tendon avulsion).
30
do PASTA (partial articular supraspinatus tendon avulsion). tend to heal
they don’t heal properly and have a tendency to progress to full-thickness tears.
31
full thickness tears are froma
articular side to bursal side
32
most tears are which msucle
supraspinatous
subscapualris is more popular than previous through
33
___ atrophy is bad if >50z5 of muscle then high rate of recurrence after surgery in full thickness tears
fat atrophy
34
massive rotator cuff tear involves
two or more tendons or a retraction greater than 5 cm.
35
risk factors for rotator cuff tears
overload, overhead movements, muscle imbalance, aging, ischemia, anatomical features (i.e. narrow coracoacromial arch), MSK disease
36
most common symptom for rotator cuff disease
Shoulder and arm pain/weakness is the most common symptom of RCD, especially during overhead activities.
* This is usually described as a dull pain becoming sharp during overhead motion.
Other symptoms include: night pain, weakness, stiffness, or crepitus heard during shoulder movement.
37
how to assess for glenohumeral motion
* Glenohumeral motion can be isolated by holding the patient's scapula with one hand while the patient abducts the arm. The first 20 to 30 degrees of abduction should not require scapulothoracic motion.
38
pain provocation tests are positive if ...
shoulder pain is induced when the rotator cuff and subacromial bursa are compressed between the humeral head, acromion, or coracoid process.
39
painful arc test
60-120 degrees is subacromial or rotator cuff disease
near 180 is impingement
near 0 is frozen shoudler
40
Pain provocation tests for rotator cuff disease
* Cross body adduction
* Neer
* Painful arc
* Passive abduction
* Hawkins
* Yocum
41
strength tests for rotator cuff disease
* Drop arm test
* Dropping sign
* External rotation lag
* Internal rotation lag
* Gerber (lift off test)
42
drop arm test is for which muscle
supraspinatorus
43
dropping sign test is for
infraspinatous
44
external rotation lag test is for
supraspinatous and infraspinatour
45
internal rotation lag test is for
subscapularis
46
composite tests for pain and weakness for rotator cuff disease
* External rotation resistance
* Full can test
* Resisted abduction
* Empty can (Jobe)
* Patte
47
external rotation resistance test is for
infraspinatous
48
empty can and full can are for
supraspiantous
49
which pain provocation test for rotator cuff disease has the highest LR
painful arc
50
which strength tests are best for detecting full rotator cuff tear
a positive external rotation page and internal rotation page test
51
what is composite test for? positive means?
positive when the patient experiences either pain or weakness during the maneuver.
52
best composite test for rotator cuff dieases
external rotation resistance test
53
highest LR for rotator cuff disease and rotator cuff tears
* Positive findings on the internal and external rotation lag tests and presence of a painful arc have the highest positive LR for RCD and rotator cuff tears.
* Most experts consider RCD more likely with increasing numbers of positive findings. Rotator cuff disease is considered much less likely when the findings on more tests are normal.
54
test recommendation for shoulder pain
* For patients with shoulder pain, it‘s recommended one perform a single pain provocation test (painful arc test), 3 strength tests (internal rotation lag test, external rotation lag test, and drop arm test), and 1 composite test (external rotation resistance test).
55
1st line of imaging for nearly all shoulder pathology
xray
56
imaging for fracture or dislocation
CT scan
57
soft tissue of shoulder for imaging
MRI
58
MRI vs ultrasound for rotator cuff disease e
* Studies suggest that MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears.
* Ultrasound may be better at picking up partial tears and it is usually more cost-effective for identification of full- thickness tears vs. MRI.
59
first line imaging for soft tissue
MRI
60
gold standard for labral tear or shoulder instbaility
MR athrography
61
prognosis of impingement
* Periarticular disorders, such as impingement, may be self-limited and respond to rest, analgesics, and range of motion and strengthening exercises.
* Impingement syndrome can be chronic and recurrent, leading to rotator cuff tendinopathy. This can ultimately progress to full-thickness rotator cuff tears and secondary glenohumeral osteoarthritis.
62
prognosis and treatment of partial rotator cuff tears
Partial rotator cuff tears may heal with non-operative treatment. Most partial rotator cuff tears can be treated with physical therapy and scapular and rotator cuff muscle strengthening.
* However, research suggests that 40% of the partial thickness tears progress to full thickness tears in 2 years
63
risks with full tears
fatty infiltration (replace muscle with fat)
* Fatty infiltration progresses in full thickness rotator cuff tears, and is a negative prognostic factor for successful surgical treatment. Fatty infiltration is an irreversible process so operative interventions are usually performed when the degree of infiltration is low.
64
calcified tendinopathy
* Crystal deposition, especially CPPD (Calcium Pyrophosphate Dihydrate Deposition Disease) deposits on the tendon, causes inflammation and is an important cause of shoulder pain in young adults.
self limiting and spontaneous resolution
65
stages of calcified tendinopathy
precalcification phase which is clinically silent; the calcification phase in which crystal deposition occurs, subsequently the start of a resorptive phase with inflammatory reaction that causes severe pain; and the end a post- calcification phase.
66
adhesive capsultis- which ROM is the most effected
characterized by pain and marked decrease of the range of motion, especially to external rotation.
67
phases of adhesive capsultiit s
acute inflammatory phase (axillary capsular thickening and capsular edema)
progress to hypervascularization and fibrosis
thickening of the coracohumeral ligament, subcoracoid fibrosis, and capsular thickening.
68
nerve denervation syndromes
supra scapular neuropathy related to compression via
an associated paralabral cyst in a superior labrum injury.
69
nerve denervation syndromes where there is no compression; what are the 2 main origins
a viral inflammation and or overuse in athletes with overhead activities.
70
acute vs chronic phases in nerve denervation syndromes
in the acute phase, supraspinatus and infraspinatus muscle edema is seen, whereas in chronic phases fatty atrophy and volume loss of the muscle are shown.
71
what is the most common axillary nerve denervation secondary cause?
anterior inferior shoulder dislocation
72
isolated greater tuberosity fractures
xx
73
what is shoulder impingement syndrome
is a painful condition of the upper extremity resulting from a structural narrowing of the subacromial space.
74
most common cause of shoulder pain?
shoulder impingement syndrome
75
what are th internal and external shoulder impingement causes?
internal = glenoid or labrum
external= subacromial space
Internal impingement occurs secondary to a repetitive impingement in overhead throwers or manual laborers and involves articular-sided rotator cuff pathology, glenohumeral internal rotation deficit (GIRD), and superior labrum anterior posterior (SLAP) tears.
external impingement- described as a painful condition that results from the inflammation, irritation, and degradation of the anatomic structures within the subacromial space.
76
3 categories of shoulder impingement
* In stage I, impingement primarily results from edema,
hemorrhage, or both.
* Stage II is characterized by greater fibrosis and
irreversible tendon changes.
* Stage III shoulder impingement syndrome is characterized
tendon degeneration of the rotator cuff as well as the long head of biceps, bony changes and tendon rupture.
77
shoulder impingement syndrome is usually from
repetitive overhead activities
bearing heavy loads, infection, smoking, and fluoroquinolone antibiotics.
78
shoulder impingement syndromes
pain when lifting arm
pain when lying on arm- affecting sleep
79
shoulder impingement imaging
xray/ radiographie
80
critical shoulder angle (CSA) for shoulder impingement if > x then bad
35
* The AP view of the shoulder can be used to determine the critical shoulder angle (CSA), which involves the extent of lateral coverage by the acromion and the inclination of the glenoid.
* At CSAs greater than 35 degrees, there is an increased likelihood that a rotator cuff is contributing to impingement syndrome.
81
acromiohumeral distance (ADH) if ___ then suggests rotator cuff patholgoy/ shoulder impingement
normal range is approximately 7 to 14 mm in men and 7 to 12 mm in women. A lower AHD suggests rotator cuff pathology.
82
prognosis for shoulder impingement syndrome
In 60% of patients, physical therapy, NSAIDs, corticosteroid injections, and other means of conservative therapy yield satisfactory results within two years.
83
what can cause complications in shoulder impingement syndrom
complications that may arise predominantly result from structural damage within the subacromial space, altered biomechanics, or avoidance of use with subsequent atrophy.
* Potential pathologies that may result include rotator cuff tendonitis or tear, bicipital tendonitis or tear, or adhesive capsulitis.
84
adhesive capsultitis/ frozen shoulder
acute inflammation --> scarring and remodelling
85
who is adhesive capsulitis/ frozen shoulder common for
* Adhesive capsulitis is seen commonly in patients aged 40– 65 years, and occurs more often in women than men, especially in perimenopausal women or in patients with endocrine disorders, such as diabetes mellitus or thyroid disease.
* There is higher incidence of adhesive capsulitis following shoulder trauma or breast cancer care (such as mastectomy), which may create a pro-inflammatory condition in the shoulder.
86
_____shoulder condition is self limiting but debilitating
adhesive capsulitis
87
3 overlapping phases of adhesive capsultiis/ frozen shoulder
* phase 1: Progressive stiffening, loss of motion in the shoulder with increasing pain on movement, which may be worse at night (months 2–9), usually referred to as the painful phase.
* phase 2: Gradual decrease in pain but stiffness remains and there is considerable restriction in the range of movement (months 4–12), usually referred to as the stiffening or ‘freezing’ phase
* phase 3: Improvement in range of movement (months 12– 42), usually referred to as the resolution phase.
88
primary vs secondary adhesive capsultitis/frozen shoulder
* Frozen shoulder can be described as either primary (idiopathic), where the etiology is unknown, or secondary, when it can be attributed to another cause.
* Secondary frozen shoulder has been defined as that associated with diabetes, trauma, cardiovascular disease and hemiparesis.
89
ROM is adhesive capusltis/frzoen shoulder
PROM and AROM restricted in all directions
A useful clinical sign is limitation of movement of external rotation with the elbow by the side of the trunk.
90
imaging fro adhesive capsultiis/ frozen shoulder
can do radiographs but its usually just a clinical diagnosis and dont need diagnostic workup
91
prognosis and time frame of frozen shouler/ adhesive capsultiis
Although for most people frozen shoulder is a self-limiting condition of approximately 1–3 years' duration, it can be extremely painful and debilitating
Recurrence is unusual
92
93
shoulder stability relies on
rotator cuff muscle strength, scapular control and the integrity of the fibrocartilaginous glenoid labrum.
94
which direction do 95% of shoulder dislocations/instability occur in?
anterior direction
Dislocations usually are caused by a fall on an outstretched and abducted arm.
* Posterior dislocations are usually caused by falls from a height, epileptic seizures, or electric shocks.
95
shoulder
96
second dislocation chance?
After a second dislocation, the recurrence rate is extremely high, up to 95%, regardless of age.
97
what is a banker lesion
Bankart lesions when the anterior inferior labrum is torn, which can lead to continued instability.
in shoulder dislocation
98
what can co-occur with anterior shoulder dislocation
An anterior shoulder dislocation can also have an associated rotator cuff injury in approximately 50% of patients under 40 years old and about 80% of patients over 60 years old.
99
what are atraumatic shoulder dislocations usually caused from?
Atraumatic shoulder dislocations are usually caused by intrinsic ligament laxity or repetitive microtrauma leading to joint instability; often seen in athletes involved in overhead and throwing sports (eg, in swimmers, gymnasts, and pitchers).
100
shoulder instability test
apprehension test, the load and shift test, and the O’Brien test.
101
what 2 lesions can be present in anterior shoulder dislocations
hill-sacks lesion (compression fracture posteriorly)
and bankart lesion
102
what is bankart lesion
damage to the labrum and glenoid rim, causing a Bankart lesion
in shoulder dislocation
103
what imaging for shoulder dislocation
radiograph/ xray
104
proximal biceps tenditinist and tendinopathy is a range of
acute inflammatory tendinitis to degenerative tendinopathy.
105
primary vs secondary bicipital tendinitis
Primary bicipital tendinitis is much less common than cases where it is associated with concomitant primary shoulder pathologies (i.e., secondary cases).
106
what does long head of bicepstendinitis often occur with
rotator cuff pathology or impingement syndrome
107
pathophysiology in proximal biceps tenditinitis to tendinopathy
here is LHB sheath thickening, fibrosis, and vascular compromise.
* The LHB tendon undergoes degenerative changes, and associated scarring, fibrosis, and adhesions eventually compromise LHB tendon mobility. In effect, the tendon becomes pathologically “anchored” in the groove, further exacerbating the potential points of traction and overall increasing shear forces experienced by the LHB tendon along its course
in advanced, end-stage conditions, the LHB tendon can eventually rupture.
108
proximal biceps tendinitis and Popeye deformity
A “Popeye” deformity is characteristic for a complete rupture of the long head biceps tendon
109
tests for proximal biceps tenditinis
bicipital groove palpation
speed test
uppercut test
yergason test
110
proximal vs distal biceps rupture
* Distal biceps rupture is from the excessive eccentric force as the arm is brought into extension from flexion. These activities include weightlifting, wrestling, and labor-intensive job.
* Proximal biceps rupture is generally not due to a unique mechanism of injury but is highly correlated with rotator cuff disease.
111
risk factors for biceps tendon rupture
Risk factors include age, smoking, obesity, use of corticosteroids, and overuse. Rare causes include the use of quinolones, diabetes, lupus, and chronic kidney disease.
112
weakness in __ for biceps tendon rupture
Weakness of flexion of the elbow and supination of the forearm in cases of distal biceps rupture.
113
prognosis of biceps tendon rupture
Proximal biceps rupture patients generally recover with non-operative treatment
Distal biceps rupture can cause persistent pain and forearm supination weakness. Also, with a complete distal biceps rupture, the tendon can retract significantly, and later repair in chronic cases would be technically challenging. Hence the timely diagnosis of distal biceps rupture is critical, especially in a young active patient.
114
acromioclavicular joint injury
AC joint injury in sports common
associated with a fractured clavicle, impingement syndromes, and more rarely neurovascular insults.
115
most common mechanism of injury for acromioclavicular injury? what position/ROM?
direct trauma to the lateral aspect of the shoulder or acromion process with the arm in adduction. Falling on an outstretched hand or elbow may also lead to AC joint separation
116
what is piano key sign for
acromioclavicular joint injury
with an elevation of the clavicle that rebounds after inferior compression.
117
type I to VI for acromioclavicular joint injury
Type I is referred to as a sprain of the acromioclavicular ligaments only and demonstrates no displacement.
* Type II involves tearing of the acromioclavicular ligament and sprain of the coracoclavicular ligament with less than 25% increase in the coracoclavicular interspace or with the clavicle elevated but not superior to the border of the acromion.
* Type I and II sprains are managed non-operatively with a sling, analgesia, ice, and physical therapy.
Type III AC joint separation involves tearing of both the acromioclavicular ligament and coracoclavicular ligaments resulting in clavicle elevation above the border of the acromion with a 25 to 100% increased coracoclavicular distance on x-ray compared to the contralateral side.
* Type III injuries are frequently managed non-operatively similar to type I and II; however, if the displacement is greater than 75%; the patient is a laborer, elite athlete, or concerned about cosmesis; or is not improving with conservative management, then surgical intervention may be considered.
Posterior displacement of the distal clavicle into the trapezius defines type IV injuries. Type V injuries have a superior displacement by more than 100% compared to the contralateral side.
* Type VI is rare and is an inferolateral displacement in a subacromial or subcoracoid displacement behind the coracobrachialis or biceps tendon.
* Type IV through VI injuries are typically managed surgically, and warrants referral to an orthopedic surgeon.
118
most common cause of acromoclavicular symptoms in adults
osteoarthritis
* Primary osteoarthrosis is due to cumulative degeneration with aging, whereas secondary osteoarthrosis is most commonly caused by previous injury
119
acromicoclavicular test
cross body adduction
120
almarm features
Fever and chills consider:
* Infection (septic arthritis, soft tissue abscess)
* Polymyalgia rheumatica (low-grade fever)
Constant and progressive pain consider:
* Referred pain
* Infection
* Tumor
Visible swelling or deformity consider:
* Septic arthritis
* Fracture
* Dislocation
* AC joint separation
* Malignant tumours
* Amyloidosis
Axillary pain consider:
* Referred pain from the mediastinum
Night pain consider:
* Infection
* Fracture
* Major rotator cuff tear
* Neoplasm
Numbness or tingling in upper extremity consider:
* Radiculopathy
* Neuropathy
* Myelopathy
* Thoracic outlet obstruction
Inability to abduct or maintain abduction consider:
* Rotator cuff tear
Shoulder pain unrelated to arm movement consider: * Referred pain
Inability to abduct or maintain abduction consider:
* Rotator cuff tear
Weight loss consider:
* Neoplasm
* Infection
* Polymyalgia rheumatica
Dyspnea consider:
* Heart disease (cardiac ischemia)
* Pulmonary embolism
* Pulmonary disease
Trauma with loss of normal shape consider: * Dislocation
Trauma or acute disabling pain/weakness consider:
* Fracture
* Dislocation
* AC joint separation
* Major rotator cuff tear
Headache or visual changes consider:
* Polymyalgia rheumatica
121
when to refer
Failure of conservative treatment over 3 months.
* Young and active patients with impingement due to full- thickness rotator cuff tears.
* Young and active patients with full-thickness rotator cuff tears.
* Partial tears with greater than 50% involvement and with significant pain.
* Acute rotator cuff tears and loss of function.
* Older and sedentary patients with full-thickness rotator cuff tears who have not responded to non-operative treatment.
* Full-thickness subscapularis tears.
* Advanced imaging (MRI) for cases lasting longer than six weeks.
* Patients who are at risk for second dislocation, such as young patients and certain job holders (eg, police officers, firefighters, and rock climbers), to avoid recurrent dislocation or dislocation while at work.
* Patients who have not responded to a conservative approach or who have chronic instability.
