Disorders and Injuries of the Shoulder part 2

Question 1

Clinical presentation of Humeral fractures

Answer 1

Severe pain
Limited ROM
Swelling
Ecchymosis (bruising)

Question 2

What classification tool is used to assess humeral fractures?

Answer 2

Neers classification

Location, fracture parts and displacement

Question 3

Most frequent cause of shoulder pain

Answer 3

Subacromial Impingement Syndrome (SAIS)

Question 4

What is the pathology that creates a Subacromial impingement syndrome?

What structures are typically involved

Answer 4

Decreased subacromial space causes repetitive mircrotruama

1. Supraspinatus tendon
2. Subacromial bursa
3. Long head tendon of bicep

Question 5

What are the three types of Acromion morphology?

Answer 5

Type 1: Flat
Type 2: Curved
Type 3: Hooked

Question 6

What affect does a Type 3 “Hooked” acromion have?

Answer 6

Decrease subacromial space

More contact with RC tendons

Increased risk of SAIS → increased risk of RC tear

Question 7

What causes a Primary Impingement?

What age is this most common in and WHY?

Answer 7

Considered degenerative changes

> 35 y/o
Bone spurs &/or calcific deposits
“true” or “classic” impingement

Question 8

What causes Secondary impingement?

Answer 8

Due to repetitive overhead movement

Abduction and ER

Question 9

Who is a secondary impingement most common in and at what age?

Answer 9

<35 y/o
Overhead athlete
Faulty scapular posture

Question 10

What contributary factors can cause secondary impingement?

Answer 10

Faulty scapular posture

• Forward head
• Increased thoracic kyphosis
• Leads to adaptive muscle imbalances

Question 11

How does muscle imbalance cause secondary impingement?

Answer 11

Tight pec minor can cause anterior tilting & protraction

↓ subacromial space → impingement → inflammation and gradual degeneration of subacromial structures

Question 12

What findings do you see during physical exam when assessing Secondary impingement?

Answer 12

Gradual onset of anterior and lateral shoulder pain (deltoid tuberosity) exacerbated by overhead activity

Night pain and difficulty sleeping on affected side

Tenderness to palpation over greater tuberosity, subacromial bursa and biceps tendon (long head)

Question 13

What special diagnostic test can you perform during physical exam if you suspect subacromial impingement

Answer 13

Neers impingement

Hawkins impingement test

Question 14

What strength test are used to assess subacromial impingement?

Answer 14

External rotation strength testing
Empty can testing
Lift off Subscapularis test

Question 15

Which imaging test would you order order for someone with subacromial impingement?

Why and for what benefit

Answer 15

X-ray

Always in cases of traumatic injury to r/o fracture
Eval for calcifications / bone spurs
Evaluation of acromial morphology

Question 16

What are initial treatments for subacromial impingement

Answer 16

NSAIDs and avoidance of offending activities
Modify sleeping position
Therapy program focusing on postural correction
-Physical therapy
-Home therapy

Question 17

If initial treatment does not help someone with subacromial impingment what other treatment is next?

Answer 17

subacromial corticosteroid injection

Question 18

What is subacromial decompression surgery recommended?

Answer 18

Failure of conservative care (NSAIDS,injection,physical thearpy

Evidence of calcification and bone spurs

Question 19

What is the MC etiology for a Rotator Cuff injury

Answer 19

Overuse MC

Others:
Age-related degeneration
Chronic mechanical impingement
Traumatic

Question 20

Which tendon do rotator cuff injuries MC originate from?

Answer 20

Supraspinatus tendon (90%)

Question 21

Clinical Presentation of a Rotator Cuff injury?

Answer 21

Recurrent shoulder pain for several months (overuse)

Specific injury that triggered the onset of the pain (traumatic)

Subacromial pain and pain localized to deltoid tuberosity

Night pain and difficulty sleeping on affected side

Weakness, catching, and grating especially when lifting the arm overhead

Question 22

slide 29

Answer 22

slide 29

Question 23

slide 29

Answer 23

slide 29

Question 24

Gold Standard imaging to diagnose Rotator cuff tear?

What must be ordered alongside with a partial tear?

Answer 24

MRI

If chronic injury and concern is for partial tear order arthrogram

Question 25

What imaging usually has to get order prior to ordering MRI? What does it look for?

Answer 25

X-ray Traumatic injuries to r/o fracture Eval for calcifications / bone spurs

Question 26

What are non-surgical treatment options for rotator cuff injuries? What kind of tear are these best used for?

Answer 26

``` NSAIDs, PT, and avoidance of overhead activities Steroid injection (should never receive > 3 subacromial injections/year) ```

Question 27

When is surgery warranted for a rotator cuff injury

Answer 27

Patient with significant symptoms and failed rehab > 3-6 months

Question 28

Patient with acute TRAUMATIC cuff tear can receive what kind of treatment? How soon?

Answer 28

Surgery Best done acutely or no later than within 6 weeks of injury

Question 29

What is Adhesive Capsulitis? (Frozen shoulder) What age group is this found in? What is the most common risk factor?

Answer 29

Idiopathic loss of both active and passive motion Most commonly affects patients 40-60 years of age DM (esp. type 1) is most common risk factor

Question 30

How does Adhesive Capsulitis occur?

Answer 30

Inflammatory process involving the glenohumeral capsule

Question 31

What is the most pronounced range of motion loss with Adhesive Capsulitis? What are other losses

Answer 31

External rotation --> MC Abduction Flexion

Question 32

What kind of pain is seen with Adhesive Capsulitis?

Answer 32

Dull / achy at rest (deltoid tuberosity) Sharp at end range of restricted movements (GH joint)

Question 33

What imaging is used to confirm suspicion of Adhesive Capsulitis?

Answer 33

MRI Radiographs help rule out other pathologies though

Question 34

What is the "Freezing" phase seen in Adhesive Capsulitis?

Answer 34

Freezing” phase - pain and progressive loss of motion

Question 35

What is the Thawing phase?

Answer 35

“Thawing” phase - decreasing discomfort associated with a slow but steady improvement in ROM

Question 36

What are initial treatment options for Adhesive capsulitis?

Answer 36

Intra-articular injection of steroid may be considered | Physical Therapy

Question 37

What is recommended when treating Adhesive capsulitis with PHysical therapy?

Answer 37

Pain prescriptions prior to therapy

Question 38

When is surgery warranted for adhesive capsulitis?

Answer 38

after 9-12 months of failed initial treatment