LECTURE 7B: SHOULDER EXAM/TREAT

Question 1

shoulder complex can be divided into 3 types of exam:

Answer 1

1. UQ scan
2. c-SPINE vs shoulder complex
3. specific joint assessment (GH, AC, SC, ST?)

Question 2

___ and shoulder complex often present similarly

Answer 2

spine and shoulder complex

Question 3

check 4 body segments/systems review with shoulder complex

Answer 3

1. Cervical spine
2. Thoracic spine
   3 .Elbow/forearm complex
3. Cardiovascular system

Question 4

3. causes of shoulder dysfunction

Answer 4

1. Compromise of passive restraint components (INSTABILITY)
2. Compromise of NM control (weak)
3. Compromise of >1 neighboring joints that contribute to motion (screwed up chain)

*assume visceral and serious causes ruled out! pancoast tumor, blood clot

Question 5

neighboring joints of the shoulder

Answer 5

AC joint, SC joint, upper thoracic spine, ribs, lower cervical spine

Question 6

If shoulder pain increases with activites and patient has history of repetitive motion:

Answer 6

tendinopathy

Question 7

If shoulder pain increases AFTER activity, and painful with prolonged static positions

Answer 7

instability (non-contractile tissue)

Question 8

humeral epiphysitis or osteogenic sarcoma associated age

Answer 8

children/adolescents

Question 9

RC degeneration associated age

Answer 9

40-60s
(may be sped up if a lot of overhead activity)

Question 10

2° impingement d/t instability (caused by weakness) typically seen in

Answer 10

teens – 20’s … especially w/ overhead athletes

Question 11

calcium deposits in shoulder are most common in _____

Answer 11

20-40 year olds

Question 12

pain during activity ____
pain after activity _____

Answer 12

pain during: active mm
pain after: passive problem (instability)

Question 13

Insidious onset of adhesive capsulitis typically seen

Answer 13

45 – 60 year olds

Question 14

DM and ischemic heart disease, female sex, 45-60s age is related to ____

Answer 14

adhesive capsulitis
can be related to any age with trauma

Question 15

MOI patterns:
Overhead exertion w/ repetitive motions

Answer 15

-Sub-acromial bursitis/impingement
-RC tendinopathy/tear
-Biceps tendinopathy

Question 16

Fall on Outstretched Hand (FOOSH) MOI pattern:

Answer 16

all bets off, can sprain or break anything

Shoulder/elbow/wrist sprain or strain
Elbow/wrist fx’s
AC joint separations
Clavicle fx’s
GH joint fx’s
GH dislocations

Question 17

If you fall on tip of shoulder, (adducted, land on it) MOI may cause

Answer 17

-AC joint separation*
-Bone contusion
-C-spine injury

Question 18

MOI: shoulder pain in swimmers

Answer 18

-Prevalence b/t 40-91%
-Likely related to fatigue of upper back, RC and pec muscles
-Repetitive stress injury impaired dynamic stabilization of humeral head

(usually very hypermobile)

Question 19

Pain relieved w/ arm elevated overhead
cause is usually

Answer 19

NOT SHOULDER BUT NECK

Question 20

Pain relieved w/ elbow supported

Answer 20

AC joint separation
RC tears

Question 21

Pain relieved by circumduction of shoulder w/ accompanying click or clunk

cause is

Answer 21

Internal derangement
GH instability

Question 22

Pain relieved w/ arm distraction

Answer 22

Bursitis
RC tendinopathy

Question 23

Pain relieved w/ arm held in dependent position

Answer 23

Thoracic outlet syndrome

Question 24

___ may suggest instability (even if it occurred a long time ago

Answer 24

history of trauma (for neck we care if it is recent, but shoulder we care about forever)

Question 25

What are the 4 buckets of shoulder STAR classification of shoulder pain?

Answer 25

1. rotator cuff/impingement 2. frozen shoulder 3. GH instability 4. post op/other catch all

Question 26

key positive findings regarding rotator cuff impingement

Answer 26

Impingement signs Painful arc Pain w/ isom resist Weakness Atrophy (common, not always)

Question 27

key negative findings with rotator cuff

Answer 27

significant loss of motion (joint issue, frozen shoulder) instability signs (instability bucket)

Question 28

Key positive findings of frozen shoulder

Answer 28

Spontaneous progressive pain Loss of motion in multiple planes *LOSE ER FIRST WILL HAVE LIKE 10 DEGREES Pain at end-range

Question 29

key neg findings of frozen shoulder

Answer 29

normal motion age less than 40

Question 30

progression of impingement to rotator cuff

Answer 30

impingement --> RC tendon --> TEAR

Question 31

50-70% of all shoulder pain seen in PT related to

Answer 31

ROTATOR CUFF

Question 32

rotator cuff classified by tear __ and ___

Answer 32

type and size

Question 33

small RC tear

Answer 33

less than 1 cm

Question 34

medium RC tear

Answer 34

1-3 cm

Question 35

large RC tear

Answer 35

usually includes infra 3-5 cm

Question 36

massive tear

Answer 36

more than 5 cm subscap + (can go supra to subscap but usually other tendons)

Question 37

___% of frozen shoulder will subsequently develop in opposite shoulder

Answer 37

20-30%

Question 38

45-60 y/o Females>males Trauma DM & thyroid disease these are associated with

Answer 38

frozen shoulder

Question 39

stages of frozen shoulder

Answer 39

Stage I (pt typically ignores) for <3 months Stage II (freezing) for 3-9 months Stage III (frozen) for 9-14 months --> not painful Stage IV (thawing) for 14+ months by 18 months, usually will resolve on its own

Question 40

treatment for adhesive capsulitis

Answer 40

stage 1: pain control stage 2: pain and Manual therapy stage 3: focus on ROM, strength as tolerated (pain usually gone) stage 4: stretch, ROM, nm re-ed, strength

Question 41

Key positive findings of GH instability

Answer 41

Age < 40 Hx disloc / sublux Apprehension Generalized laxity

Question 42

If patient asks about how long frozen shoulder will last, they are in stage 2, what do you say?

Answer 42

say recovery will last over a year most likely -shoulder will be losing motion -shoulder will be frozen, PT not needed -shoulder will start regaining motion

Question 43

key negative findings of GH instability

Answer 43

no history of dislocation no apprehension

Question 44

MRI of frozen shoulder will show

Answer 44

capsule INFLAMMED WHITE

Question 45

post op/other differential dx includes:

Answer 45

1. GH Arthritis 2. Fractures 3. Epiphysitis 4. AC joint 5. Neural Entrapment 6. Myofascial 7. Fibromyalgia 8. Post-Op

Question 46

GH joint instability is what?

Answer 46

abnormal, SYMPTOMATIC motion of GH joint affecting normal joint kinematics *laxity does not equal instability*

Question 47

causes of GH instability

Answer 47

genes collagen biomechanical factors

Question 48

signs and symptoms of GH joint instability

Answer 48

feel like it will fall or slip out pain, sublux/dislocation

Question 49

MOI of GH joint instability

Answer 49

Trauma Unidirectional Bankart Surgery Atraumatic, multidirectional, bilateral, rehab, inferior

Question 50

what is more than 90% of of all shoulder dislocations?

Answer 50

anterior dislocation (automatically get a labral tear, enough times you also get a humeral head lesion) MOI: ABD, EXT, ER

Question 51

SLAP lesion looks like

Answer 51

RC disease and GH instability MOI: trauma, microtrauma

Question 52

posterior dislocation MOI

Answer 52

flexion, ADDUCTION, IR Associated w/ seizures, electric shock, diving into a shallow pool and MVAs (football, benchpress when you are older), less than 2% of dislocations

Question 53

inferior dislocation happens when

Answer 53

Extremely uncommon MOI: carrying heavy objects & hyperabduction

Question 54

Alterations in normal position or motion of the scapula during coupled scapulo-humeral movements (i.e. elevation)

Answer 54

scapular dyskinesis

Question 55

MOI: bony morphology Δ’s following trauma age: over 45

Answer 55

traumatic OA

Question 56

separated shoulder: trauma due to falling onto tip of shoulder OR chronically trauma due to OA, RA, mechanical

Answer 56

AC joint dysfunction

Question 57

6 types of AC joint and treatment

Answer 57

Types I-II – conservative management Type III – controversial Types IV-VI – surgical reduction

Question 58

posterior dislocations of SC joint can be

Answer 58

life threatening! Sprain vs dislocation 2/2 fall on flex/add or ext/add arm

Question 59

Most commonly fx’d bone in childhood

Answer 59

clavicle 5-10% of all fxs in body

Question 60

Most common humeral fracture in children & elderly

Answer 60

proximal 1/3 of humerus (ice cream cone!) FOOSH or fall right on it.

Question 61

TSA/RTSA involves

Answer 61

whacking humerus with spike

Question 62

scapular fxs are __% of all fxs in the body

Answer 62

1% (usually immobilization, ORIF if displaced)

Question 63

outcome measures of the shoulder

Answer 63

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