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Clinical Medicine II > Common Shoulder Pathology > Flashcards

Common Shoulder Pathology Flashcards

1
Q

Common shoulder orthopedic impairments

A
  • Subacromial rotator cuff impingement
  • Glenohumeral instability
  • Glenohumeral dislocation: Bankart lesion or Hill-Sachs lesion
  • Adhesive capsulitis
  • AC joint sprain
  • Clavicular fracture
  • Humeral fracture
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2
Q

Describe primary subacromial rotator cuff impingement

A
  • primary impingement = supraspinatus tendinopathy
  • possibly poor vascularity: watershed zone
  • degeneration of acromion
  • mechanical friction with overhead movements
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3
Q

Describe secondary subacromial rotator cuff impingement

A
  • loss if normal biomechanics: movement along a non-physiological axis
  • loss of normal inferior humeral glide with upward humeral rotation (flexion, abduction)
  • crowding of supraspinatus tendon under corcoarcromial arch
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4
Q

Describe Neer’s 3 stages of subacromial rotator cuff impingement

A
  • Stage 1: young (<25 y/o), edema and hemorrhage, & pain with >90 degrees abduction
  • Stage 2: age 25-40 y/o, fibrosis, irreversible changes in supraspinatus or bicep tendon, & pain at night, difficulty positioning shoulder for comfort
  • Stage 3: operative?, age >40 y/o, tendon degeneration/supraspinatus tears, history of shoulder pain, & muscle weakness/atrophy
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5
Q

Rehab priorities for subacromial rotator cuff impingement

A
  • scapular stabilization: serratus anterior, middle/lower traps, & levator scapulae
  • glenohumeral/scapulothoracic mobilization
  • capsular stretches
  • activity modification
  • modalities for pain & inflammation
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6
Q

Describe phase 1 rehab for subacromial impingement

A
  • pre-functional phase
  • sleeper stretch (posterior capsule)
  • self mobilization (lateral distraction & thoracic extension)
  • scapular stabilization in physiological axes
  • taping/blocking
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7
Q

Describe phase 2 and 3 rehab for subacromial impingement

A
  • Phase 2: functional return, progression of scapular stabilization & removal of taping/blocking
  • Phase 3: functional recovery
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8
Q

Describe subacromial decompression (SAD) surgery for subacromial impingement

A
  • shaving acromion
  • detachment of coracoacromial ligament
  • almost always arthroscopic
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9
Q

Surgical management for subacromial impingement

A
  • activity modification throughout rehab: avoid increased inflammation/delayed recovery
  • positioning: sleep and ADLs
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10
Q

SAD rehab weeks 0-6

A
  • sling 2-7 days, but early mobilization encouraged
  • PROM or AAROM to ensure full available range: done daily until full ROM achieved
  • posture emphasized or corrected
  • scapular stabilization begins: initially below horizontal so as to prevent movement along a non-physiological axis
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11
Q

SAD rehab weeks 6-10 and 10-14

A
  • once ROM achieved, ensure physiologic movement in available range
  • scapulohumeral/scapulothoracic balance
  • once scapular stability achieved progress to overhead movement
  • pain free ROM with adequate strength
  • functional activities/sport-related activities weeks 10-14
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12
Q

Describe the MOIs for the different sublet/dislocation of the glenohumeral joint

A
  • Anterior sublux/dislocation: shoulder horizontal abduction with external rotation
  • Posterior sublux/dislocation: shoulder adducted, internally rotated, and loaded
  • Multi-directional instability: congenital laxity or subluxation may be anterior, posterior, or inferior
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13
Q

Describe dislocation

A
  • complete separation of humeral head from glenoid cavity
  • humerus does not spontaneously reduce
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14
Q

Describe subluxation

A
  • partial separation, results in soft tissue strain at shoulder
  • humerus spontaneously reduces
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15
Q

Management for subluxation

A
  • avoid unstable position
  • taping or blocking maybe needed in initial stage
  • initial focus on coordination, endurance, & proprioception
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16
Q

Management for dislocation

A
  • reduced in emergency room or other urgent care environment
  • period of protection
  • avoid unstable positions
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17
Q

Operative management for glenohumeral instability

A
  • arthroscopic anterior stabilization surgery
  • laxity of capsule is decreased
  • rehab begins 1-3 weeks after surgery
  • early controlled motion (avoid external rotation and extension)
  • goals: restore strength, ROM, flexibility, and propreioception
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18
Q

Rehab following anterior stabilization surgery weeks 1-3

A
  • immobilizer when not exercising
  • external rotation & extension limited to neutral
  • flexion/elevation to 90 degrees via AAROM
  • scapular stabilization (isometric)
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19
Q

Weeks 3-6 rehab following anterior stabilization surgery

A
  • external rotation to 45 degrees
  • immobilizer discontinued (per surgeon)
  • AAROM/wand exercises
  • scapular stabilization progressed: no humeral movement
20
Q

Weeks 6-12 rehab following anterior stabilization surgery

A
  • full AROM
  • progress scapular stabilization with UE movement & weight bearing
  • PNF patterns
  • functional movements avoiding previously unstable position
21
Q

Weeks 12-18 rehab following anterior stabilization surgery

A
  • more sport or activity specific
  • plyometrics added
22
Q

Describe a Bankart lesion

A
  • avulsion of capsule & glenoid labrum off anterior glenoid rim
  • result of traumatic anterior shoulder dislocation
23
Q

Describe a Hill-Sachs lesion

A
  • a compression or “impaction fracture” of the posteromedial aspect of the humeral head after anterior shoulder dislocation
24
Q

Describe the 4 types of a labral tear

A
  • Type I: degeneration of superior labrum, loss of horizontal abduction with external rotation
  • Type II: detachment of labrum & biceps tendon anchor with loss of stability
  • Type III: vertical tear of labrum, biceps intact
  • Type IV: tear of labrum into biceps tendon
25
Q

Conservative treatment of labral tears

A
  • avoid painful positions PRICEMEM
  • scapular stabilization
  • closed chain exercises
  • coordination of scapulohumeral rhythm
26
Q

Surgical repair of labral tear

A
  • Bankart lesion (from shoulder dislocation): reattachment of torn capsule & labrum to glenoid
  • SLAP (superior labral tear from anterior to posterior) lesion repair: debridement of torn labrum & reattachment of labrum & bicep tendon
27
Q

Describe Bankart surgical rehab

A
  • Immobilization 1-8 weeks: maintain hand, wrist, & elbow ROM; CV fitness maintained
  • Anterior Bankart repair: avoid anterior dislocation position (i.e external rotation with horizontal abduction)
  • Reverse Bankart repair: avoid flexion >90 degrees, horizontal adduction, & internal rotation
28
Q

Describe a SLAP repair rehab

A
  • 0-2 weeks: flexion limited to 60 degrees, ER limited to 15 degrees in neutral, IR limited to 45 degrees in neutral, & pendulum exercises
  • 3-4 weeks: flexion limited to 90 degrees, ER limited to 30 degrees & IR to 60 degrees, & wand exercises
  • 5-8 weeks: progress to full ROM
  • Subacute phase (8-12 weeks post-op): horizontal ABD/ADD, PNF patterns, IR & ER strengthening with arm in protected position (towel roll), & progressive UE weight bearing (hands & knees)
29
Q

Describe adhesive capsulitis (AKA frozen shoulder)

A
  • GH joint hypo mobility due to development of dense adhesions, capsular restrictions, and thickening
  • insidious onset b/w 40-60 y/o
  • associated with trigger points, guarding of subscapularis
  • probably but not conclusively inflammatory
30
Q

Describe primary & secondary adhesive capsulitis

A
  • Primary: idiopathic
  • Secondary: systemic origin, extrinsic origin, or intrinsic origin
31
Q

Stages of development of adhesive capsulitis

A
  • Freezing (2-3 weeks); continuous pain including at rest, severe limitation of movement soon after onset
  • Frozen (4-12 months): atrophy, pain (although less, & occurring primarily with movement), loss of ROM
  • Thawing (12-24+ months): decreased pain, restricted ROM
32
Q

Describe rehab for adhesive capsulitis

A
  • PROM & AAROM in pain free range (physiological axis)
  • joint mobilization/self mobilization exercises
  • soft tissue massage/trigger point release of subscapularis, upper traps, and levator scapulae
33
Q

Describe AC sprain/dislocation

A
  • direct force to acromion or when force is transmitted proximally to AC from FOOSH
  • graded by degree of injury to specific ligamentous structures
34
Q

Degrees of AC sprains/dislocation

A
  • Grade 1: AC joint sprain with minimal loss of function
  • Grade 2: AC sprain with moderate pain and some dysfunction
  • Grade 3: AC with coracoclavicular ligament injury that may have significant dysfunction
35
Q

Rehab for AC joint sprain grade 1 and 2

A
  • sling 1-2 weeks
  • followed by ROM
  • once pain free add isometric exercises to the clavicular and scapular muscles
36
Q

Rehab for AC joint sprain grade 3

A
  • acute first 2-4 weeks: physical therapy to decrease pain & swelling and reinforce immobilizer use
  • return to function based on pain level & tolerance for activity: ROM and strengthening
37
Q

Describe a clavicle fracture

A
  • 4-15% of all fractures
  • 35% of shoulder fractures
  • MOI: direct trauma or indirect trauma (FOOSH)
  • most are treated non-surgically with sling use for 3-4 weeks
38
Q

ORIF indications for a clavicle fracture

A
  • open fracture
  • displaced fractures with impending skin compromise
  • neuromuscular compromise
  • widely displaced mid-clavicular fractures
  • shortening or gross displacement are risk factors for development of a non-union fracture
  • sling following surgery for 6 weeks
39
Q

Describe humerus fractures

A
  • 4-5% of all fractures
  • increase age = increased incidence
  • 85% are minimally displaced
40
Q

What are the 4 typical fragments of a humerus fracture

A
  • humeral head
  • greater tuberosity
  • lesser tuberosity
  • humeral shaft
41
Q

Minimally or non-displaced humeral fracture management

A
  • sling
  • early PROM within 14 days (avoid adhesive capsulitis)
  • AROM at 4-6 weeks
42
Q

Describe fractures of the humeral neck

A
  • 2 part humerus fracture
  • most common displaced humeral fracture
  • closed reduction or ORIF
43
Q

Describe fractures of the humerus greater tuberosity

A
  • 2 part humerus fracture
  • occur with shoulder dislocation
  • ORIF if displaced
44
Q

Describe 3 part humerus fractures management

A
  • ORIF
45
Q

Describe 4 part humerus fractures

A
  • ORIF: young patient and good bone quality
  • humeral head replacement: elderly

Clinical Medicine II (21 decks)

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