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1022 THEORY > Week 4 Shoulder conditions and different diagnosis > Flashcards

Week 4 Shoulder conditions and different diagnosis Flashcards

1
Q

why are shoulders good to treat?

A
  • highly mobile joint
  • relies on active stability
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2
Q

red flags for shoulder conditions

A
  • infection
  • unreduced dislocation
  • tumour
  • acute cuff tear
  • neurological pathology or injury
  • cardiovascular or visceral impairment
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3
Q

symptoms/ signs of infection

A
  • red, hot, swollen joint
  • severe pain
  • possible fever, fatigue, feeling unwell if sepsis 敗血症
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4
Q

action for infection

A

refer to ED

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5
Q

symptoms/ signs of unreduced dislocation

A
  • traumatic history
  • abnormal shoulder shape
  • reduced range of motion
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6
Q

action for unreduced dislocation

A

refer to ED

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7
Q

symptoms/ signs of tumour

A
  • soft tissue mass 軟組織腫塊
  • swelling (unexplained by trauma)
  • history of cancer
  • night sweats
  • UWL
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8
Q

action of tumour

A

refer to GP

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9
Q

symptoms/ signs of acute cuff tear

A
  • traumatic history
  • pain and shoulder weakness
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10
Q

action of acute cuff tear

A

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。

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11
Q

symptoms/ signs of neurological pathology or injury

A

sudden motor or sensory loss

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12
Q

action of neurological pathology or injury

A

refer to GP or ED

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13
Q

symptoms/ signs of cardiovascular or visceral impairment

A

eg: cardiac event (heart attack) referral of pain to left shoulder

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14
Q

action of cardiovascular or visceral impairment

A

refer to ED

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15
Q

special questions for shoulder injuries

A
  1. Has your shoulder ever ‘popped’ in and out, felt unstable for felt like it came out of the joint?
  2. **Pain at rest? **
  3. Neurological symptoms in the arm or hand e.g. tingling
    刺痛, shooting pain, numbness
  4. Severity, duration and impact on function – e.g. can they get dressed, sleep at night, do things around the house

referr to 1 - consider glenohumeral dislocation or sublaxation
referr to 2 - consider inflammatory conditions e.g. Adhesive capsulitis
referr to 3 - consider cervical nerve root compression or peripheral nerve injury
referr to 4 - This can help guide treatment and management decisions

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16
Q

diagnosis of acromioclavicular joint injuries

A
  • localised pain to AC joint site
  • pain with horizontal flexion
  • pain with elevated overhead
  • possible step deformity 畸形 (X-ray can see)
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17
Q

rockwood classification of injury (acromioclavicular joint injuries)

A

type I
- sprain of the capsule
- localized pain
- 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

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18
Q

management of acromioclavicular joint injuries

A
  • 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
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19
Q

sternoclavicular joint injuries

A
  • 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
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20
Q

diagnosis of sternoclavicular joint injuries

A
  • mainly observation and palpation
  • tenderness of SC joint after trauma
  • complete dislocation
  • difficulty swallowing
  • CT scan may help
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21
Q

management for sternoclavicular joint injuries

A
  • ice + sling for 2-3 days
  • high likelihood of pain and subsequent arthritis
  • mild sprain: resolve within 7-10 days
  • moderate sprain: take 3-6 weeks (anywhere up to 12 weeks)
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22
Q

pathophysiology of adhesive capsulitis (frozen shoulder)

A
  • idiopathic
  • inflammatory thickening of joint capsule
  • increased vascularity and neural tissues
  • reduces capsular volume – decreased ROM
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23
Q

4 stages of adhesive capsulitis (frozen shoulder)

A

stage 1 - pre-adhesion
stage 2 - acute adhesive capsulitis
stage 3 - maturation
stage 4 - chronic

(1,2: many pain, less adhesion, have ROM
3,4: less pain, more adhesion, loss of ROM)

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24
Q

stage 1- pre-adhesion of frozen shoulder

A

no adhesions
full ROM
night pain

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25
Q

stage 2 - acute of frozen shoulder

A

forming adhesions
mild loss of ROM
pain+
hypertrophy of synovium 滑膜肥大

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26
Q

stage 3 - maturation of frozen shoulder

A

fibrosis begins
reduction in ROM
less pain

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27
Q

stage 4 - chronic of frozen shoulder

A

dense fibrotic adhesions 緻密纖維化粘連
loss of ROM
minimal pain

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28
Q

risk factors of frozen shoulder

A
  • 40-65 years old
  • female > male
  • can be after trauma
  • diabetes
  • thyroid disease
  • history of cervical spine, shoulder or breast surgery
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29
Q

management of frozen shoulder

A

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

30
Q

diagnosis of biceps tendinopathy

A
  • 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
31
Q

management of biceps tendinopathy

A

load management
progressive loading
address glenohumeral and scapula mechanics and function

32
Q

biceps rupture

A
  • relatively rare
  • obvious deformity - ‘Popeye sign’
  • can be little pain and biceps strength is almost fully maintained 几乎没有疼痛，肱二头肌力量几乎完全保持不变
  • surgical management
33
Q

umbrella term - subacromial pain syndrome

Info

A
  • Rotator cuff disorders
  • Rotator cuff tendinopathy
  • Subacromial impingement syndrome
  • Rotator cuff impingement/syndrome
  • Shoulder impingement
  • Rotator Cuff Related Pain Syndrome
34
Q

signs and symptoms of subacromial pain syndrome

A
  • most common type of shoulder pain (70%)
  • exacerbated 加剧 with repetitive/ overhead activities
  • reduced elevation ROM
  • pain around the lateral deltoid/ deltoid insertion
  • painful arc
  • weakness and pain with ER and abduction strength testing
35
Q

special tests for the shoulder

A
  • Hawkins-Kennedy
  • Neer’s
  • Empty can
  • Jobe’s
  • ER resistance
  • Painful arc
36
Q

Self-Reported Questionnaires – Validated Outcome Measures of subacromial pain syndrome

Info

A
  • 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)
37
Q

MRI or Diagnostic Ultrasound recommended if:
(diagnostic imaging of subacromial pain syndrome)

A
  • Traumatic injury
  • Clinical suspicion 懷疑 of full Thickness Rotator Cuff Tear
  • Conservative management has failed
38
Q

full thickness rotator cuff tear (specific in subacromial pain syndrome)

A
  • older adults/ trauma in younger athletes
  • > 50% of age 70-80 people may present cuff tears
  • full thickness tears increase with age
39
Q

diagnosis of full thickness rotator cuff tear

A
  • decreased strength of ER/ IR
  • decreased elevation ROM and painful arc
40
Q

yellow flags of subacromial pain syndrome

A
  • patient expectation
  • expectations of recovery with physio treatment
  • employment status
  • lack of social support
41
Q

conservative management of subacromial pain syndrome and rotator cuff tear

A
  • exercise therapy (shoulder strength and endurance exercises)
  • education (pain education, anatomy and function of the shoulder)
  • manual therapy (stretching, passive mobilisation of GH joint and massage)
42
Q

anterior glenohumeral dislocation

A
  • often traumatic
  • most common direction
  • arm forced into excessive abduction and external rotation
  • 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
43
Q

bankart-lesion vs hill-sachs lesion

A

Bankart Lesion - compression fracture of the glenoid
Hills Sachs Lesion - compression fracture of posterior humeral head

44
Q

symptoms/ signs of GH dislocations

A
  • popping noise or sensation of giving way
  • numbness over lateral shoulder if damage to axillary nerve
  • prominent humeral head
  • deltoid is depressed
  • acromion protrudes 突顯 with hollow below
45
Q

why x-ray is required for GH dislocations

A
  • 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 fracture greater tuberosity
  • preferable prior to relocation
  • must be done post-reduction
46
Q

GH dislocations reduction 位錯減少

A
  • ASAP
  • difficult due to
    –> muscle contraction
    –> displacement of humeral head into the joint capsule
    –> ligament strain
47
Q

posterior GH dislocation

A
  • less common
  • direct trauma or fall on outstretched hand with IR and adduction
48
Q

signs/ symptoms of posterior dislocation

A
  • arm held in IR/ adduction (unable to ER)
  • loss of anterior contours 前部輪廓喪失
49
Q

first time traumatic dislocations have

A

high rate of shoulder dislocation reoccurrence

50
Q

convervative managment of GH joint dislocations

A
  • immobilised 3 weeks no ER at all
  • avoid abduction and external rotation (in first 6 weeks)
51
Q

rehabilitation of GH joint dislocation

A
  • isometric scapular and rotator cuff strengthening
  • improve neuromuscular control (proprioception)
  • return to sports (RTS) 2-3 months (3-4 months with bankart lesion)
52
Q

how does recurrent dislocation occur

A

capsule ligament and labour are more lax than they were. it heals but are not tight or strong as before

53
Q

risk factors of shoulder instability

A
  • age
  • severity of initial trauma 初始創傷的嚴重程度
  • limited or no immobilization 固定 of the shoulder after first dislocation
  • presence bankart lesion/ hill-sachs lesion
54
Q

clinical features of anterior instability of GH joint

A
  • Recurrent dislocation or subluxation
  • ‘pop out’ or ‘doesn’t feel right’
  • ‘dead arm’ syndrome
  • Shoulder pain (usually from impingement of RC with anterior translation of humeral head) → rotator cuff tendinopathy
  • Catching sensation
55
Q

special tests for anterior GH joint instability

A
  • apprehension test
  • relocation test
  • inferior instability
56
Q

posterior GH instability

A
  • Most commonly atraumatic 無創傷性
  • able to voluntarily posteriorly subluxate
  • +ve posterior drawer
  • treated with strengthening of the posterior stabiliser muscles (surgery if fails)
57
Q

physiotherapy management of instability

A
  1. scapular stability
  2. rotator cuff strengthening
  3. proprioceptive and functional retraining
  4. biomechanical analysis
58
Q

instability

A

the humeral head moves within the confines (area) 在範圍內 of the shoulder socket

59
Q

subluxation

A

humeral mead moves part way out of the shoulder socket

60
Q

dislocation

A

humeral mead moves completely out of the shoulder socket

61
Q

importance of biomechanical and postural analysis

Info

A

Swimmers:
* Increased thoracic kyphosis
* Imbalance between IR and ERs (impingement)
* Hypermobility/ instability‐fatigue of RC

Throwers:
*Open stance (eg not side on) Increases anterior/ER stress on GH joint capsule
*Poor recruitment of gluteal/ leg drive will increase stress on GH joint

62
Q

functional progression

A
  1. scapular stabilising
  2. isometric RC exercises
  3. rotator cuff exercises at 0 degrees Abd
  4. rotator cuff exercises at 90 degrees Abd
63
Q

SLAP lesions

superior labrum anterior to posterior

A
  • tears around the point where long head of biceps tendon attaches to superior labrum
  • relatively poor healing
64
Q

4 types of SLAP lesions

A

type I tear; fraying 磨損 of the labrum
type II tear, type III tear, type IV tear

65
Q

mechanism of SLAP lesions

A
  • forceful LH biceps contraction
  • traumatic event vs repetitive action
    –> overhead activities (throwing)
    –> inferior traction (lifting a heavy object)
66
Q

symptoms of SLAP lesion

A
  • poorly localised shoulder pain 肩部疼痛局部不明顯
  • popping
67
Q

physical examination of SLAP lesion

A

palaption - bicipital groove tenderness
resisted elbow flexion
muscle wasting

68
Q

special clinical tests for SLAP lesion

A

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)

69
Q

clavicle fracture

A
  • Fall on point of shoulder 摔倒在肩部
  • Localised pain and bony deformity
  • Requires X-ray
  • 4-6 weeks immobilised
70
Q

SNOH #

A
  • 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

1022 THEORY (10 decks)

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