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-
instabilityor altered glenohumeral motor patterning/ function -
pain reproduced on stretching of bicepsor resisted shoulder/ elbow flexion local pain on palpation biceps tendon
management of biceps tendinopathy
load management
progressive loading
address glenohumeral and scapula mechanics and function
biceps rupture
relatively rare- obvious deformity -
'Popeye sign' - can be
little pain and biceps strength is almost fully maintained surgical management
umbrella term - subacromial pain syndrome
Info
- Rotator cuff disorders
- Rotator cuff tendinopathy
- Subacromial impingement syndrome
- Rotator cuff impingement/syndrome
- Shoulder impingement
- Rotator Cuff Related Pain Syndrome
signs and symptoms of subacromial pain syndrome
- most common type of shoulder pain (70%)
exacerbated 加剧 with repetitive/ overhead activitiesreduced elevation ROM-
pain around the lateral deltoid/ deltoid insertion painful arc- weakness and pain with ER and abduction strength testing
special tests for the shoulder in subacromial pain syndrome
- Hawkins-Kennedy
- Neer’s
- Empty can
- Jobe’s
- ER resistance
- Painful arc
Self-Reported Questionnaires – Validated Outcome Measures of subacromial pain syndrome
Info
- American Shoulder and Elbow Surgeons Shoulder Score
- Rotator Cuff Quality of Life Index
- Shoulder Pain and Disability Index
- Upper Extremity Functional Index
- Western Ontario Rotator Cuff (WORC)
MRI or Diagnostic Ultrasound recommended if:
(diagnostic imaging of subacromial pain syndrome)
- Traumatic injury
- Clinical suspicion 懷疑 of full Thickness Rotator Cuff Tear
- Conservative management has failed
diagnosis of full thickness rotator cuff tear (specific in subacromial pain syndrome)
- older adults or trauma in younger athletes
- >50% of age 70-80 people may present cuff tears
- full thickness tears increase with age
diagnosis:
- decreased strength of ER/ IR
- decreased elevation ROM and painful arc
yellow flags of subacromial pain syndrome
- patient expectation
- expectations of recovery with physio treatment
- employment status
- lack of social support
.
conservative management of subacromial pain syndrome and rotator cuff tear
-
exercise therapy (shoulder
strengthand endurance exercises) -
education (
pain education, anatomy and function of the shoulder) -
manual therapy (
stretching,passive mobilisation of GH jointandmassage)
definition of instability, subluxation and dislocation
instability:
the humeral head moves within the confines (area) 在範圍內 of the shoulder socket
subluxation:
humeral mead moves part way out of the shoulder socket
dislocation:
humeral mead moves completely out of the shoulder socket
anterior glenohumeral dislocation
- often traumatic, common in:
young athletes (men) -- sporting injuryolder people (women 61-70 yo) -- fall- most common direction - 95% cases
- arm forced into excessive abduction and external rotation
- tackling player, trauma with arm in ‘stop sign’ position, fall
- humeral head - anterior and inferiorly displaced
- can result in damage to: anterior capsule/ glenohumeral ligaments, bankart lesion, bony bankart lesion, hill-sachs lesion, tearing of posterior/ superior labrum, vascular or nerve injury
bankart-lesion vs hill-sachs lesion
Bankart Lesion - compression fracture of the anteroinferior glenoid margin
Hills Sachs Lesion - compression fracture of posterior humeral head
symptoms/ signs of GH dislocations
- popping noise or sensation of giving way
- numbness over lateral shoulder if damage to axillary nerve
- prominent humeral head
- deltoid is depressed
- loss of normal contour 輪廓
- acromion protrudes 突顯 with hollow below
- humeral head palpated under the coracoid process
why x-ray is required for GH dislocations
- to eliminate bony damage 以消除骨骼損傷
1. glenoid (i.e. bankart lesion)
2. posterior humeral head (i.e. hill-sachs’ lesion)
3. avulsion 撕脫 fracture greater tuberosity - preferable prior to relocation but not always practical 但並不總是可行
- must be done post-reduction
GH dislocations reduction 位錯減少
- ASAP
-
difficult due to
->muscle contraction due to pain
->displacement of humeral head into the joint capsule
.
symptoms/ signs, reduction of posterior GH dislocation
- less common
- direct trauma or fall on outstretched hand with IR and adduction
symptoms/ signs:
- arm held in IR/ adduction (unable to ER)
- loss of anterior contours 前部輪廓喪失
reduction: forward traction of humerus
first time traumatic dislocations have
high rate of shoulder dislocation reoccurrence, especially in younger athletes
convervative managment of GH joint dislocations
- non operative rehabilitation is common
-
immobilised in sling for 2 weeks:
–> IR VS ER immobilisation
–> ER maybe more effective
no difference
–> traditional sling may worsen Bankart lesion - rehabilitation (6 months):
- isometric scapular and RC strengthening
- improve neuromuscular control (proprioception)
- RTS 2-3 months (3-4 months with Bankart lesion)
- reconditioning and progressive strengthening of RC and scapular muscles (trapezius and serratus anterior)
how does recurrent dislocation occur
capsule ligament and labour are more lax than they were. It heals but are not tight or strong as before
shoulder instability classification
mechanism of injury, direction and severity
mechanism of injury:1. traumatic
- often from an initial acute injury producing a dislocation
- fall, a direct hit, or force applied to the outstretched arm
2. atraumatic
- less common
- develops slowly without any history of previous injury (repetitive overhead work, such as throwers, swimmers)
direction: anterior, posterior, inferior and multi-directional
severity: dislocation vs sublaxation
risk factors of shoulder instability
- age
- severity of initial trauma 初始創傷的嚴重程度
- presence bankart lesion/ hill-sachs lesion
- limited or no immobilization 固定 of the shoulder after first dislocation
clinical features of anterior instability of GH joint
-
Recurrent dislocationor subluxation - shoulder is going to ‘
pop out’ or ‘doesn’t feel right’ - episodes 發作 of
‘dead arm’ syndrome -
Shoulder pain(may also have rotator cuff tendinopathy) Catching sensation- active and passive ROM (generalised ligamentous laxity 全身韌帶鬆弛 and the amount of ER)
- special clinical tests (apprehension test, relocation test)
special tests for anterior GH joint instability
- apprehension test
- relocation test
- inferior instability
posterior GH instability
-
Most commonly atraumatic無創傷性 - able to voluntarily posteriorly subluxate
+ve posterior drawer-
treated with strengthening oftheposterior stabiliser muscles(surgery if fails)
multidirectional instability (MDI)
- difficult to diagnose
interview:
- often no traumatic event 通常沒有創傷事件
- generalised hypermobility
- multiple times of subluxation 多次半脫位 - low irritability
- potential history of overhead sport participation
objective tests:
test battery:
- anterior apprehension and posterior apprehension test
- hyperabduction test (>105 degrees)
physiotherapy management of instability
- scapular stability and mobility (could include biomechanical analysis)
- rotator cuff strength, endurance, symmetry (0 degrees abd to elevation)
- upper limb strength, endurance, symmetry
- thoracic mobility, posture, strength
- proprioceptive and functional retraining (consider sport or positions of instability)
what is SLAP lesions
superior labrum anterior to posterior
- tears around the point where LH of biceps tendon attaches to superior labrum
relatively poor healing- unstable vs stable
mechanism of SLAP lesions
- forceful LH biceps contraction
- traumatic events:
–> inferior traction (lifting a heavy object) - overuse/ chronic use
–> overhead activities (throwing)
–> natural degeneration of laburm - aging
the history gives a lead as to the diagnosis may hear a ‘clunk’
what type of SLAP lesions is the most common
there are 10 types of SLAP lesions
type II: detechment of superior labrum and tendon of LH biceps from the glenoid rim 邊緣
symptoms, physical examination and special clinical tests of SLAP lesion
symptoms:
- poorly localised shoulder pain
- noises
physical examination:
- palaption - bicipital groove active compression (LHBT)
- movements: resisted elbow flexion
- observation - muscle wasting
special clinical tests:
anterior slide test (positive if pain or click is elicited in anterior shoulder)
O’brien test (positive if pain increases)
crank test (positive if occurs pain, catching or grinding in the shoulder 肩部磨傷)
MRI is standard for diagnosis
common fractures of shoulder
- clavicle
- middle 1/3 clavicle #
- clavicle #:
- Fall on point of shoulder 摔倒在肩部 or direct blow
- Localised pain and bony deformity
- Requires X-ray
- 4-6 weeks immobilised
-
greater tuberosity
- maybe associated with anterior GH dislocation or RC tear
- if non/ minimal displacement can be managed conservatively
- immbolise sling for 6 weeks - allow PROM exericse from 2-3 weeks with x-ray monitoring -
SNOH#
- Fall on outstretched hand 跌倒時用手撐地時導致的一系列傷害，有可能傷到肩膀、手肘、前臂、手腕等
* Direct trauma
* Minimally displaced fractures treated conservatively 輕微移位骨折保守治療
* Comminuted-surgical
Management:
* 4-6/52 sling, isometric strengthening, ROM, cuff strengthening
