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MSK > Shoulder Complex Common Clinical Presentations > Flashcards

Shoulder Complex Common Clinical Presentations Flashcards

1
Q

Fractures of the proximal humerus are often caused by what two things?

A
  1. FOOSH (Fall on out-stretched hand)

2. Direct trauma to the areas

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2
Q

Those who are at increased risk of Fracturing the proximal humerus are what two groups?

A
  1. Children (growth plate)

2. Older adults (osteopenic/ osteoporotic bone)

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3
Q

Conservative treatment of Fractures of the proximal humerus includes what methods?

A

nondisplaced & stable (no surgery)

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4
Q

Surgical outcomes of Fractures of the proximal humerus are poor/increased risk for complications when patient has what factors?

A
  1. Hx smoking
  2. DM
  3. RA
  4. Neoplasms
  5. Severe osteoporosis
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5
Q

What is ORIF for Fractures of the proximal humerus?

A

Open Reduction Internal Fixation - Incision made to get to fraction site and hardware is placed to stabilize

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6
Q

Neurovascular structures possible involved with fractures of the proximal humerus?

A
  1. Circumflex Humeral Artery

2. Axillary Nerve (check function of lateral arm sensory and deltoid function)

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7
Q

Clavicle fractures account for what % of all fractures?

A

5-10%

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8
Q

Clavicle fractures are commonly related to what 2 types of injuries?

A
  1. FOOSH

2. Direct Trauma

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9
Q

What potential secondary vascular/neurologic injuries to clavicle fractures?

A
  1. Brachial plexus passes deep to middle clavicle
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10
Q

When a clavicle fracture heals out of alignment, what is the possible outcome?

A

angled downward might impinge on neurovascular structures

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11
Q

What 4 things are you looking for in a physical examination for a clavicle fracture?

A
  1. Guarded shoulder motion
  2. Supporting UE with contralateral UE
  3. Deformity (palpate bulge)
  4. Extreme tenderness
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12
Q

What 2 signs should you check that are consistent with secondary brachial plexus injury due to clavicle fracture? What should you not test?

A
  1. Radial pulse
  2. Neuro testing (sensation)

Do not test myotome -> can worsen injury

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13
Q

80% of SC joint injuries are found in what 2 types of injuries?

A
  1. Sport

2. MVC

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14
Q

Describe the difference in joint stability (subluxed, unstable, stable) and ligament integrity (complete disruption, none, partial) for SC joint sprains:
Mild -
Moderate -
Severe -

A
  1. Mild: stable joint without ligament integrity compromise
  2. Moderate: subluxed joint with partial ligament compromise
  3. Severe: unstable joint with complete ligament disruption
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15
Q

A patient with SC joint injury will present with what 4 things?

A
  1. Hx
  2. Observable deformity
  3. Local tenderness
  4. Pain with shoulder motion
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16
Q

What are 3 possible mechanisms for AC joint injury?

A
  1. Fall
  2. Spot
  3. MVC
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17
Q

If the AC is damaged in an ac joint injury, what motion will this compromise?

A

compromised horizontal stability

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18
Q

If the CC is damaged in an ac joint injury, what motion will this compromise?

A

compromised vertical stability

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19
Q

In the physical exam of an AC joint injury, what 5 things are you looking for?

A
  1. Weakness with shoulder (AROM/MMT)
  2. Local Tenderness (+ AC Joint Palpation Test)
  3. Possible observable deformity
  4. Possible Swelling
  5. Pain with shoulder motion
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20
Q

The most common type 1 separation of an AC joint injury includes injury to what ligament with what type of joint instability?

A
  1. AC lig sprain

2. No joint instability

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21
Q

Type 2 separation of an AC joint injury includes injury to what ligament with what type of joint instability?

A
  1. Ruptured AC ligament and Sprained CC lig

2. Clavicle unstable

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22
Q

For a Type 1/2 separation of an AC joint injury,
How long is the patient immobilized?
What exercises do you begin with?
What exercises do you progress to?

A
  1. Typically brief period of immobilization/ sling use (1-2 weeks)
  2. Gentle ROM (PROM->AROM), isometric exercises
  3. Progression to scap stab exercises
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23
Q

Type 3 separation of an AC joint injury includes injury to what ligament/muscles with what type of joint instability?

A
  1. Rupture of AC and CC lig and detached deltoid and trap muscle
  2. Clavicle unstable in vertical and horizontal planes
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24
Q

For a type 3 separation of an AC joint injury, describe difference between surgery vs. conservative method.

A
  1. Immobilized
  2. Progress to PROM 2-3 weeks after
  3. Progress to shoulder strengthening
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25
Q

If limitations of type 3 separation of an AC joint injury persist for >/= 3 months, what should occur?

A

reconstruction

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26
Q

Type 4 separation of an AC joint injury includes injury to what ligament/muscles?

A

Rupture of all supporting structures and clavicle displaced through trap muscle

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27
Q

For type 4,5,6 separation of an AC joint injury, how is it immediately managed? Progression?

A
  1. Surgically managed
  2. Progress toward full ROM/strength
  3. Manual therapy as appropriate
  4. Scap stab/proprioceptive training
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28
Q

Scapular dyskinesia is defined as abnormal movements to the scapula, including:

A

Decrease:

  1. posterior tilting
  2. Upward rotation
  3. Clavicle retraction
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29
Q

A hyperactive ____ muscle and impaired motor performance of ____ muscles can lead to scapular dyskinesia

A
  1. Hyperactive upper trap
  2. Impaired motor performance
    - Lower & Mid Traps
    - Serratus Anterior
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30
Q

Diminished soft tissue extensibility/flexibility of what can cause scapular dyskinesia?

A
  1. Pec minor
  2. Posterior capsule tightness - push head of humerus anterior
  3. Levator scap, lats, GH ER
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31
Q

What is calcific tendonitis of the rotator cuff?

Females (>/

A

Calcification of the tendons - biceps/supraspinatus tendons

Females>males

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32
Q

What is rotator cuff tendinosis?

A

Microtrauma

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33
Q

What tissue abnormalities can lead to Subacromial Impingement of the rotator cuff?

A
  1. Anatomic abnormalities of acromion
  2. Bursitis
  3. Calcific bone spur
  4. Tendon thickening
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34
Q

What other abnormalities can lead to Subacromial Impingement of the rotator cuff?

A
  1. Altered scapulothoracic/scapulohumeral kinematics
  2. Postural abnormalities (foreword head posture and rounded shoulders)
  3. Superior translation of humeral head during elevation
    - Decreased GH joint stability
    - “tight” posterior capsular
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35
Q

What is the typical clinical progression of tendonitis of the rotator cuff?

A

Tendonitis -> degenerative tendinopathy ->partial thickness tear ->full thickness tear

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36
Q

What is the goal when working with a patient who has tendonitis of the rotator cuff?

A

stop movement to later stages

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37
Q

What symptoms/functional activities are difficult for patient with rotator cuff tendinopathy?

A
  1. Dull ache lateral upper/ lower arm
  2. Reaching away from body painful
  3. Abduction difficult
  4. Over shoulder-level activities painful
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38
Q

Where is the common pain distribution of rotator cuff tendinopathy?

A

Lateral proximal upper arm

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39
Q

Why is there a possibly painful GH arc when lifting arm above head? What is the degree of arc?

A

where we need posterior tipping but it’s lacking

60-120 deg of shoulder elevation

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40
Q

T/F Tender at tendon insertion of rotator cuff tendinopathy.

A

True

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41
Q

With a patient with rotator cuff tendinopathy, where will we see muscle guarding?

A

Muscle guarding peri-scapular musculature (traps)

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42
Q

With a patient with rotator cuff tendinopathy, where will we see muscle tightness?

A

Pec minor

43
Q

With a patient with rotator cuff tendinopathy, where will we see decreased capsule length?

A

Posterior

44
Q

With a patient with rotator cuff tendinopathy, where will we see muscle performance impairments?

A

Serratus anterior and lower trap

45
Q

T/F Long-Term outcomes of surgical management are comparable to conservative intervention for rotator cuff tears

A

True, Persistent pain/ disability > 1/3 of patients (regardless of Tx)

46
Q

What type of resistance (if any) used on Traumatic tear vs degenerative tear of rotator cuff?

A
  1. Traumatic tear (no resistance testing)

2. degenerative tear (gradual process, total absence of resistance during MMT)

47
Q

Physical examination of rotator cuff tears:

A
  1. Significant weakness with shoulder (limited AROM, weak/ absent shoulder resistance testing)
  2. Compensation with scapular motion when attempting to elevate UE (skipping supraspinatus downward motion on humeral head)
48
Q

With older adults >60 postural changes, you see more thoracic kyphosis which can lead to what changes to the humeral head?

A

humeral head more anterior -> not as good posterior tipping of scapula and impingement occurs

49
Q

What is the critical zone for older adults >60 in regard to their rotator cuff?

A

supraspinatus is no longer vascular so when tearing starts, it can not repair

50
Q

Infiltration of what into the supraspinatus and infraspinatus muscle tears that will influence rotator cuff strength and is a negative prognostic factor?

A

Fatty infiltration

51
Q

Biceps tendon instability is commonly associated with what muscular tears?

A

subscap tears (inability to hold humeral head in anterior motion)

52
Q

Bicep tendon tendinopathy mechanism?

A

microtrauma

53
Q

Bicep tendon tendinopathy tender where?

A

in bicipital groove

54
Q

Bicep tendon tendinopathy pain with what (tests)?

A

with tensile loading (MMT supination, flexion, Yorgason’s test, speed test)

55
Q

Rupture of the biceps tendon commonly occurs where?

A

occur at origin or upon exit of bicipital groove

56
Q

Common presentation of a bicep tendon rupture?

A
  1. Popeye deformity (bulge, biceps muscle retracts distally)
  2. Most commonly age > 50 years
  3. Hx biceps tendinosis
57
Q

What is adhesive capsulitis?

A

pathological process that effects capsule – irritation, synovial hypertrophy

58
Q

What is the incidence of adhesive capsulitis?

A

a. Incidence 3-5 %
b. Women > Men
c. 5th and 6th decades of life

59
Q

What are risk factors for adhesive capsulitis?

A

i. DM (5-6x more likely)

ii. Prior history in either shoulder

60
Q

What is the normal progression of adhesive capsulitis (how many years)?

A

Normal function regained ~ 2 years following onset

61
Q

Describe adhesive capsulitis stage 1: pre-adhesive

A

(0-3 months)

  1. Early loss of ER ROM with intact strength
  2. hyper vascular, hypertrophic synovitis; and normal capsular tissue
62
Q

Describe adhesive capsulitis stage 2: freezing stage

A

(4-12 months)

  1. Multidirectional motion loss
  2. “thickened, hyper vascular synovitis described as having a Christmas tree appearance”
  3. Loss of axillary fold (necessary so humerus can drop down in elevation – if not bicep tendon, bursa aggravation)
63
Q

Describe adhesive capsulitis stage 3: Maturation

A

9-15 months

  1. Symptoms:
    - Pain at end-range and possibly at night
    - Significant multi-directional A/PROM limitations
  2. Tissue: Less synovitis, progressive capsuloligamentous fibrosis
  3. Loss of axillary fold
64
Q

Describe adhesive capsulitis stage 4: Thawing

A

15-24 months

  1. Symptoms
    a. Minimal pain
    b. Gradual return in ROM
    c. Stiffness may remain
  2. Tissue: Fibrosis remain, receding synovial involvement
65
Q

What are the pharmacologic medical interventions for adhesive capsulitis?

A

NSAIDs, oral steroids (decrease inflammatory response early stages)

66
Q

What is MUA for adhesive capsulitis? What are the increased risk? What is the goal?

A

MUA (manipulation under anesthesia – opening capsule up)

  1. Increased risk for: fracture (humerus), subscapularis rupture, labral tear, and biceps tendon injury
  2. Goal: Get them into clinic soon to maintain ROM up
67
Q

What is Hydro dilatation (Brisement) for adhesive capsulitis?

A

using fluid to stretch joint out within

68
Q

What is arthroscopy for adhesive capsulitis?

A

going in with scope to clean out area, open up capsule areas to promote increase ROM

69
Q

What is open release for adhesive capsulitis?

A

incision to access capsule (more tissue damage)

70
Q

OSTEOARTHROPATHY of the Glenohumeral Joint is more commonly seen in patients who:

A
  1. Have Hx of shoulder injury/chronic pain

2. Older age

71
Q

What is the symptom of OSTEOARTHROPATHY of the Glenohumeral Joint?

A

Anterolateral shoulder pain

72
Q

What are you looking for in the physical exam of OSTEOARTHROPATHY of the Glenohumeral Joint?

A
  1. Multi-directional A/PROM limitations (pain/ firm or bony end-feel)
  2. Audible/ palpable crepitus
  3. Shoulder weakness/ dyskinesia
  4. Diminished joint mobility
  5. Possible relief of pain with traction mobilization
73
Q

T/F OSTEOARTHROPATHY of the AC Joint can cause concomitant impingement syndrome and/ or rotator cuff tendinopathy.

A

True

74
Q

What are the symptoms of OSTEOARTHROPATHY of the AC joint?

A

i. Pain local to area of ACJ

ii. Painful with overhead activities (full elevation) /reaching across trunk

75
Q

What are you looking for in the physical exam of OSTEOARTHROPATHY of the SC joint?

A

i. Focal tenderness ACJ line
ii. Painful/ limited shoulder AROM (elevation, horizontal adduction)
iii. Hypomobility of ACJ

76
Q

What is AMBRI of a hypermobile shoulder?

A

Atraumatic Multidirectional Bilateral for Rehabilitation and possibly Inferior capsular shift surgery (generally hypermobile throughout entire body, CT disease)

77
Q

What is TUBS of a hypermobile shoulder?

A

Traumatic Unilateral Bankart needing/ responding to Surgery

78
Q

What are the common MOI of posterior shoulder hypermobility?

A
  1. Seizure
  2. electric shock
  3. trauma (diving into pool, MVC)
79
Q

What are the symptoms of posterior shoulder hypermobility?

A
  1. Symptoms of instability with shoulder in flexed/ abducted position (pushing door open)
  2. Pain severe
80
Q

What are you looking for in the physical exam of a posteriorly hypermobile shoulder?

A
  1. Limited/ painful shoulder AROM (ER, elevation)

2. Observable prominence posterior shoulder

81
Q

What is the common MOI of inferior shoulder hypermobility? What symptom?

A

Carrying heavy object by side

Pain

82
Q

What are you looking for in the physical exam of an inferiorly hypermobile shoulder?

A
  1. Shoulder locked in abducted position

2. Sulcus observable (gapping at lateral joint line)

83
Q

What is the most common direction of GH dislocation?

A

Anterior (the least stable)

84
Q

What is the common MOI of anterior shoulder hypermobility?

A

abduction/ ER/ extension

85
Q

What is the symptom of anterior shoulder hypermobility?

A
  1. Feeling of shoulder mal-placement following acute event
86
Q

What are you looking for in the physical exam of an anteriorly hypermobile shoulder?

A
  1. Observed self-immobilization by patient (slightly abducted/ externally rotated)
  2. Spasm/ guarding to stabilize the joint
  3. Positive instability tests (modified relocation test)
  4. Possible hypomobility of posterior G-H capsule
  5. Painful/ limited AROM
  6. Painful/ limited/ guarded PROM
87
Q

What is a Hill-sacks lesion, a potential complications of anterior dislocation?

A

compression of the posterior humeral head secondary to impaction of glenoid

88
Q

What is a Bankart lesion, a potential complications of anterior dislocation?

A

Avulsion injury of anterior inferior labrum

+/- capsular injury

89
Q

What are the presentations of a Bankart lesion?

A

a. Clicking/ clunking/ popping/ locking
b. Deep shoulder pain
c. Hx trauma (dislocation), recurrent subluxations

90
Q

T/F There is not a greater risk among young athletes subsequent glenohumeral dislocation following initial dislocation.

A

False, there is

a. <20 y/o: 70-85%
b. 20-40 y/o: 50-70%
c. > 40 y/o: 10-15%

91
Q

Multi-directional instability of the shoulder joint

A
  1. Hypermobility syndrome
  2. Pt may report ability to sublux G-H joint at will
  3. Repetitive stress can increase risk of degenerative changes to rotator cuff, joint surfaces, and other bony/soft tissue structures
92
Q

What is a SLAP lesion?

A

Superior Labral lesion that are both Anterior and Posterior (bicep tendon inserts)

93
Q

SLAP lesions are associated with what type of athletes?

A

Overhead athletes

94
Q

T/F Patient with SLAP lesion commonly presents with concomitant rotator cuff lesion.

A

True

95
Q

What is the presentation of a SLAP lesion?

A
  1. Aggravation with repetitive overhead activities
  2. Hx FOOSH/ traction trauma
  3. Glenohumeral IR ROM limitations
  4. Muscle performance impairments (scapulothoracic, scapulohumeral, rotator cuff)
  5. Locking/ clicking/ popping/ catching with shoulder motion
  6. Most often concomitant rotator cuff/ intra-articular/ biceps tendon/ ACJ injuries
96
Q

Describe a type 1 SLAP lesion

A

Fraying and degeneration of the superior labrum with a normal biceps tendon anchor

97
Q

Describe a type 2 SLAP lesion

A

Fraying of the superior labrum, but hallmark is pathologic detachment of labrum and biceps anchor from superior glenoid

98
Q

Describe a type 3 SLAP lesion

A

Superior labrum has vertical tear analogous to bucket-handle tear
Remaining rim of labral tissue is well anchored to glenoid and biceps anchor is intact

99
Q

Describe a type 4 SLAP lesion

A

Vertical tear of superior labrum and extends to a variable extent up into the biceps tendon as well

100
Q

Pitchers with GIRD will exhibit what ER -> IR arc

A

136.9° ER and 40.1° IR at 90° abduction

101
Q

Pitchers with GIRD will have an increase in retroversion of how many?

A

17 deg

102
Q

Pitchers with GIRD will have stronger what movements? Weaker what movements?

A
  1. Throwing shoulder stronger with IR and ADDuction, 2. weaker with ER
103
Q

The overhead throwing athlete will present with what type of posture?

A
  1. Protracted, anteriorly tilted scapula
  2. Pec minor tightness &/or guarding
  3. Lower trap weakness

MSK (18 decks)

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