Week 4 Shoulder conditions and different diagnosis Flashcards
why are shoulders good to treat?
- highly mobile joint
- relies on active stability
red flags for shoulder conditions
- infection
- unreduced dislocation
- tumour
- acute cuff tear
- neurological pathology or injury
- cardiovascular or visceral impairment
symptoms/ signs and action of infection
symptoms/ signs:
- red, hot, swollen joint
- severe pain
- possible fever, fatigue, feeling unwell if sepsis 敗血症
action: refer to ED
symptoms/ signs and action of unreduced dislocation
symptoms/ signs:
- traumatic history
- abnormal shoulder shape
- reduced range of motion
action: refer to ED
symptoms/ signs and action of tumour
symptoms/ signs:
- soft tissue mass 軟組織腫塊
- swelling (unexplained by trauma)
- history of cancer
- night sweats
- UWL
action: refer to GP
symptoms/ signs and action of acute cuff tear
symptoms/ signs:
- traumatic history
- pain and shoulder weakness
action: In younger athletic patients consider orthopaedic referral if candidate for RC repair
對於年輕的運動患者,如果適合 RC 修復,請考慮骨科轉診。
symptoms/ signs and action of neurological pathology or injury
symptoms/ signs:
sudden motor or sensory loss
action: refer to GP/ ED
symptoms/ signs and action of cardiovascular or visceral impairment
symptoms/ signs:
eg: cardiac event (heart attack) referral of pain to left shoulder
action: refer to ED
special questions for shoulder injuries
- Has your shoulder ever ‘popped’ in and out, felt unstable for felt like it came out of the joint?
- Pain at rest?
- Neurological symptoms in the arm or hand e.g. tingling
刺痛, shooting pain, numbness - Severity, duration and impact on function – e.g. can they get dressed, sleep at night, do things around the house
refer to 1 - consider glenohumeral dislocation or sublaxation
refer to 2 - consider inflammatory conditions e.g. adhesive capsulitis
refer to 3 - consider cervical nerve root compression or peripheral nerve injury
refer to 4 - This can help guide treatment and management decisions
diagnosis of acromioclavicular joint injuries
stability is provided by: joint capsule, AC ligaments, coracoclavicular ligament
most common site of injury when the person falls onto the point of the shoulder, or outstretched arm
diagnosis:
- localised pain to AC joint site
- pain with horizontal flexion
- pain with elevated overhead
- possible step deformity 畸形 (X-ray can see)
rockwood classification of injury (acromioclavicular joint injuries)
type I
- sprain of the capsule
- localized pain (particularly horizontal flexion)
- 0-2 weeks recovery
type II
- complete tear of AC ligament and sprain of coracoclavicular ligaments
- well localized tenderness
and palpable step deformity
- 3-6 weeks recovery
type III to VI
- complete tears of coracoclavicular ligaments
- marked step deformity
- type IV, V, VI much rarer than I, II and III
management of acromioclavicular joint injuries
- ice and analgesics 止痛藥
- immobilisation in a sling for pain relief (2-3 days for type I or up to 6 weeks in severe type III)
- cervical spine ROM
- isometric exercises and gentle mobilisation once pain permits
- protective taping
- type IV, V, VI and type III that failed conservative management require surgical management –> avoid contact sports for 8-12 weeks
sternoclavicular joint injuries
- uncommon
- from compression forces to the chest (MVA, sports)
- sprain
–> mild: ligaments intact and joint stable
–> moderate: ligaments partially disrupted and joint subluxed
–> severe: joint dislocation - anterior dislocation is more common than posterior
diagnosis of sternoclavicular joint injuries
- mainly observation and palpation
- tenderness of SC joint after trauma
- complete dislocation may lead to difficulty swallowing
- CT scan may help
management for sternoclavicular joint injuries
- ice + sling for 2-3 days
- high likelihood of pain and subsequent arthritis 疼痛和隨後的關節炎的可能性很高
- mild sprain: resolve within 7-10 days
- moderate sprain: take 3-6 weeks (anywhere up to 12 weeks)
pathophysiology of adhesive capsulitis (frozen shoulder)
- idiopathic
- inflammatory thickening of joint capsule
- increased vascularity and neural tissues - maybe a source of pain
- reduces capsular volume – decreased ROM
4 stages of adhesive capsulitis (frozen shoulder)
stage 1 - pre-adhesion
: no adhesions, full ROM, night pain
stage 2 - acute adhesive capsulitis
: forming adhesions, mild loss of ROM, pain +, hypertrophy of synovium 滑膜肥大
stage 3 - maturation
: fibrosis begins, reduction in ROM, less pain
stage 4 - chronic
: dense fibrotic adhesions, loss of ROM, minimal pain
(1,2: many pain, less adhesion, have ROM
3,4: less pain, more adhesion, loss of ROM)
risk factors of frozen shoulder
- 40-65 years old
- female > male
- can be after trauma
- diabetes
- thyroid disease
- history of cervical spine, shoulder or breast surgery
management of frozen shoulder
stage 1-2: pain management
- corticosteroids
- gentle exercise when acute pain settles
- joint mobilisation, stretching
- prevent effects of immobilisation
stage 3-4: improve ROM
- education
- exercise to improve ROM when acute pain settles
- joint mobilisation, stretching
diagnosis of biceps tendinopathy
overuse
-
instability
or altered glenohumeral motor patterning/ function -
pain reproduced on stretching of biceps
or resisted shoulder/ elbow flexion local pain on palpation biceps tendon