May30 M1-Shoulder Injuries

Question 1

swimmer shoulder = what type of injury + def

Answer 1

overuse injury (short term compared to inflam things like RA)

• bc of repetitive sub-maximal loading
• tissue fatigue
• inadequate recovery** (no rest)
• chronic degradation of affected tissue***
• no tissue adaptation
• microtrauma to inflammatory response to tissue damage
• cumulative mictrotrauma

Question 2

tendinitis vs tendinosis

Answer 2

• tendinitis = inflammation around tendon itself (tenosynovial fluid)
• tendinosis = degeneration with microtears

Question 3

tendinosis is not to be confused with what problem

Answer 3

acute sprains

Question 4

sprain def + testing

Answer 4

• physical damage to passive soft tissue (ligaments, joint capsules) (sprain with p for passive)
• test with ligament stress test, stability testing, palpation

Question 5

strain def + testing

Answer 5

• physical damage to active soft tissue (muscle, tendon, myofascial)
• test with strength testing, flexibility testing, palpation

Question 6

grading of sprains and strains

Answer 6

• grade 1 = disruption of some fibers (acute microscopic tearing)
• grade 2 = partial tear (considerable disruption) (macroscopic tearing)
• grade 3 = complete tear (macroscopic tearing)

Question 7

how swimmer shoulder (overuse injury) differs from acute tears

Answer 7

• acute tear = know exactly when happened
• overuse = gradual onset
• overuse = pain at rest and at night

Question 8

swimmer shoulder specific symptoms

Answer 8

• pain occurs earlier in training with time
• anterior or lateral pain
• painful at certain mvmt
• pain at rest
• pain at night (indicates impingement)
• RC weakness WITH PAIN

Question 9

RC muscles

Answer 9

• subscapularis
• infraspinatus
• teres minor
• supraspinatus

Question 10

most affected RC muscle in swimmer shoulder

Answer 10

supraspinatus. most likely impinged in subacromial space

Question 11

things to assess on swimmer shoulder physical exam

Answer 11

• impingement tests

- instability

Question 12

management of swimmer shoulder

Answer 12

PHYSIOTHERAPY

• active rest (rest but do other sport to stay active)
• dry land training (cycling) especially lower extremities

Question 13

what do PTs assess for swimmer shoulder

Answer 13

• RC injury?
• scapular stabilizer weakness (the primary problem in swimmer shoulder)?
• passive soft tissues too loose or too tight?

Question 14

RC in swimmer shoulder

Answer 14

• often affected but is not the cause
• is affected secondarily to the first problem (which is scapular stabilizer weakness)
• It is in ACUTE injuries that RC is affected first

Question 15

structures in the subacromial space

Answer 15

bottom to top = humerus, then muscle (inflamed if impingement), then bursa filled with fluid, then hooked acromion linked to coracoacromial ligament)

Question 16

subacromial impingement is what

Answer 16

• RC travelling between acromion and humeral head (supraspinatus m. or other m.)
• reduced space in that area so muscle impinged and inflamed. less ROM bc hits the acromion earlier

Question 17

what is the cause of a long term (not acute) RC injury

Answer 17

an imbalance between stabilizer (the RC muscles) and mobilizer muscles

Question 18

how can you assess for scapular stabilizer weakness

Answer 18

check for winging

Question 19

how do you assess for posterior shoulder stiffness (seen not in swimmers but in throwing sports)

Answer 19

• flex forearm 90 degress + ABDuct 90 degrees lie on bed
• test ROM arm most to back and front (external and internal rot)
• 0 degrees = hand to the sky
• normal = 110 deg ext 70 deg int
• abnormal = 135 deg ext 45 deg int (still 180 deg but lose internal rotation)

Question 20

cause of posterior shoulder stiffness

Answer 20

repetitive rotation causes stress on RC bc it is stretched at end of ROM or internal rotation

Question 21

posterior capsule tighteness is what

Answer 21

tightness of the glenohumeral capsule (ligament) in the back causing impingement (blocking humeral head on glenoid fossa bc pushing on humeral head forward)

Question 22

tx of overuse injuries

Answer 22

• address the underlying weakness or problem
• NSAID? (if yes, short term)
• steroid injection?
• surgery?

Question 23

tx of swimmer shoulder specifically

Answer 23

• 7-10 days NSAIDs (NSAIDs for a year in RA, not here)
• subacromial steroid injection (if constant pain and PT doesn’t help anymore)
• surgery if pain persists (but is not common for tendinosis)

Question 24

surgery for swimmer shoulder is when

Answer 24

• labral tear (tear of labrum, the cartilage)

- anatomic anomaly of acromion (hooked)

Question 25

most frequently dislocated joint

Answer 25

glenohumeral -often anterior -rarely posterior (is a contact injury)

Question 26

what's the vulnerable position for anterior dislocation of the shoulder

Answer 26

forced extension, ABDuction, external rotation

Question 27

diff hx you can see in anterior shoulder dislocation

Answer 27

- acute trauma first time felt it popping - no acute trauma (dislocates with simple activities like putting jacket on) - recurrent dislocators (multidirectional instability)

Question 28

PE in anterior shoulder dislocation

Answer 28

- tenderness around shoulder - pt passive and reluctant to moving - hollow below acromion - possible C5 axillary nerve damage (lose sensation on lateral shoulder)

Question 29

(imp) what's a Bankart lesion

Answer 29

injury to anterior labrum due to anterior shoulder dislocation *labrum attachment to ant glenoid*

Question 30

(imp) what's a bony Bankart lesion

Answer 30

anterior glenoid rim fracture due to anterior shoulder dislocation

Question 31

what's a Hill-Sachs lesion

Answer 31

impression (compression) fracture posterior superolateral side seen in anterior shoulder dislocation

Question 32

other problems seen in anterior shoulder dislocation

Answer 32

- RC tears - greater tuberosity fractures * these are in elderly + can have axillary n. damage*

Question 33

imaging for anterior shoulder dislocation

Answer 33

- XR trans-scapular Y views and AP, lateral, axillary view for bone - US or MRI for RC tear - CT or MRI for subtle fractures like Bankart (glenoid rim) - 3T MRI or MR-arthrogram for labral tear

Question 34

(EXAM) posterior shoulder disloation charact

Answer 34

- from direct high energy trauma or seizures or electrocution - arm in internal rotation or ADDuction - sudden contraction of internal rotators which are stronger than external for example

Question 35

(EXAM) reverse Bankart lesion is what

Answer 35

injury to posterior labrum | *labral attachment to posterior glenoid*

Question 36

(EXAM) reverse bony bankart is what

Answer 36

posterior glenoid rim fracture

Question 37

reverse Hill-Sachs lesion is what

Answer 37

impression fracture antero-medially

Question 38

associated injuries with posterior shoulder dislocations

Answer 38

- RC tears - LESSER tuberosity fractures - axillary n. damage is rare

Question 39

imaging for posterior shoulder dislocation.

Answer 39

same as anterior

Question 40

tx of acute shoulder dislocation

Answer 40

- reduce (replace) the humerus. **have to assess neurovascular status before and after** - easier with less muscle spasm

Question 41

contraindications to reducing a shoulder dislocation

Answer 41

- subclavicular or intrathoracic dislocation | - humeral neck fracture

Question 42

what do you do post shoulder reduction

Answer 42

sling immobilization for 1-3 weeks + PT

Question 43

(EXAM) education to give after shoulder dislocation

Answer 43

- anterior = no abduction + external rotation for 6 weeks (stresses capsule and torn ligament) - posterior = avoid internal rotation and adduction for 6 weeks

Question 44

tx for recurrent shoulder dislocation

Answer 44

- lot of PT - bracing - surgery (+ if assoc injury)

Question 45

early surgery for shoulder disloc reasons to do

Answer 45

- avoids recurrent instability and dislocation which is common in young - more stable = less OA

Question 46

what's an absolute indication for surgery in shoulder dislocation

Answer 46

``` associated injuries (is the most important one) + other things like failed rehab, etc. ```