Shoulder Flashcards
(133 cards)
1
Q
shoulder
CROSS BODY ADDUCTION TEST:
A
- AC sprain, pathology
- Patient: sitting
- Have the patient flex shoulder to 90°
- Examiner horizontally adducts the patient’s arm to end range
- +ve test is pain reproduction
2
Q
shoulder
Which is the most common type of shoulder dislocation?
A
80-90% are anterior
3
Q
shoulder
Types of RCT surgeries:
A
- Athroscopic (doens’t mean it heals faster)
- Mini-open: masive tears, partial deltoid detachment
- Open: deltoid detachment
4
Q
shoulder
When does the structural inspection occur during the examination process?
A
after ROS, then make a decission to refer out
before the screening exam
5
Q
shoulder
Labral tears usually present with:
A
RCT
6
Q
shoulder
Humeral shaft Fx healing time and tx:
A
- rapid healing
- ORIF
- immobilization achieved by cast, splint, external fixation
- PROM until fx is healed
7
Q
shoulder
What is AMBRI?
A
- Atraumatic
- Multidirectional
- Bilateral (frequently)
- Rehabilitation (often responds to)
- Inferior capsular shift (surgery)
AKA Multidirectional Shoulder Instability
8
Q
shoulder
What is a Bankart lesion?
A
- Detachment inferior GHL complex
- 3-7 o’clock
- common with dislocations
9
Q
shoulder
when does PROM (a. osteokinematic b. arthrokinematic) occur during the examimation?
A
after AROM
before Resistive test (MMT / MSTT)
10
Q
shoulder
Visceral organs can refer pain to R and L shoulder:
A
-
Right shoulder: liver, stomach, pancreas, gall
bladder - Left shoulder: heart, spleen
- Both: Pancoast’s Tumor
11
Q
shoulder
MOI of shoulder dislocation
A
AB/ER
12
Q
shoulder
Why a Humeral Shaft Fx may damage the radial nerve? How would asses a radial nerve injury?
A
- radial nerve raps around the the mid shaft of the humerus
- sensation examination
13
Q
shoulder
when does resistive test: MMT / MSTT, occur during the exam?
A
after PROM
before muscle lenght (if needed)
14
Q
shoulder
Pain with clicking during over head motions could be…
A
labral tear
15
Q
shoulder
Difficulty moving the arm not due to pain:
A
- nerve issue
- frozen shoulder (adhesive capsulitis)
16
Q
shoulder
The higher the positive LR…
A
the better it is
17
Q
shoulder
when does ROS occur during the examination?
A
after history
before structural inspection
18
Q
shoulder
Structures that give pasive stability to the shoulder:
A
- bony fit
- capsule
- labrum
- ligaments:
- SGHL (0 degress)
- MGHL (45 degrees)
- IGHL (90 degress)
- CHL (0 degrees)
- CAL
19
Q
shoulder
What type of joint is the AC joint?
A
plane joint
20
Q
shoulder
Adhesive capsulitis tx:
A
- Modalities
- Mobilization
- Stretching
- Corticosteroid injection (after one month of PT)
- Manipulation under anesthesia (if no progress in 6 months)
21
Q
shoulder
Type I slap associated with:
A
RCT
22
Q
shoulder
Arm feels loose or slips “in or out”
A
possible dislocation, instability
23
Q
shoulder
Moderate irritability pain scale:
A
4-6/10
24
Q
shoulder
which RC muscles are prone to lenghten?
A
supraspinatus and infraspinatus
25
# shoulder
What happens in a **GRADE II AC sprain**?
Surgery? Sling for how long?
Back to normal in how long?
* **Complete Tear** of the AC ligament and a **sprain** (stretching) of the CCL
* No surgery. Sling 2-4 weeks
* Rehab a minimun of 3 months
26
# shoulder
Stages of adhesive capsulitis:
1. **Pre-adhesive stage:** Mild synovitis patients present with mild end-range pain
2. **Freezing stage:** Thickened synovitis acute discomfort and very painful end range movement
3. **Frozen stage:** Less synovitis and mature adhesions significant
stiffness with less pain (established contractures)
4. **Thawing phase:** Capsular restrictions without synovitis painless stiffness motion slowly improves
27
# shoulder
Treatment of a prox humerus fx that opend reduced
* Some evidence that ‘immediate’ PT compared to 3 weeks immobilization (then PT) had reduced pain and better function for non-displaced fractures
28
# shoulder
Which ligament s give the greatest passive stability to the shoulder at rest?
* SGHL
* CHL
29
# shoulder
How is atraumatic multidirectional bilateral instability of the shoulder treated?
* Rahabilitation initially **(3months)**
* Inferior capsular shift repair (incision of the capsule)
30
# shoulder
Adhesive capsulitis:
Limitations
Demographics
Other facts?
* Limitation in ext rotation the most
* Insidious onset
* Usually between 40-65 years old with an incidence greater in females
* There is between 5-35% chance it happens on the other side
* Increases to 10-40% in patients with diabetes or thyroid dysfunction
31
# shoulder
What is the position of the pt for palpattion of infasp/teresminor?
prone on elbows, shifting their weight to the side being palpated
32
# shoulder
most common fxs?
humerus and clavicle
33
# shoulder
What is the goal of adhesive capsulitis PT tx?
* **GOAL: treat based on irritability**
* **LESS is MORE**
34
# shoulder
True or false:
Adhesive capsulitis increases to 10-40% in patients with diabetes or thyroid dysfunction
true
35
# shoulder
Pt c/o R shoulder pain that does not change with rest. Activities/movements do not change symptoms
referred pain from **liver**, **stomach**, **pancreas**, **gall
bladder**
36
# shoulder
Post operative **Massive \> 5cm RCT** guideline:
* Sling: 8 weeks
* Full PROM: 12 weeks
* Isotonics: 12 weeks
37
# shoulder
AC sprain examination test?
* AC compression
* Cross body ADD
38
# shoulder
When are **special tests** performed in the examination process?
after muscle lenght if needed
before palpation
39
# shoulder
two capsular labral pathologies:
* SLAP: 10-2 biceps involved, **avoid biceps contractions**
* Bankart: 3-7 (R) or 5-9 (L)
40
# shoulder
Is the biceps tendon attached to the superior labrum?
yes
41
# shoulder
50 y/o overweigh man, smoker, c/o billateral shoulder pain that does not change with rest. Activities does not change the symptoms:
**Pancoast’s Tumor,** referred pain
## Footnote
*A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers.*
42
# shoulder
scapular winging (internal rot)?
tiping?
* SA weakness (long thoracic n damage)
* Short pec minor
43
# shoulder
Rule in RCT:
1. Supraspinatus weakness
2. Weakness in ER
3. Positive impingement signs
* Nigh pain
* Over 60 y/o?
44
# shoulder
Most common clavicle fx?
Mechanism of fx?
middle 1/3rd ~ 80%
fall onto or a direct blow to the shoulder, giving an axial compressive force on the clavicle
45
# shoulder
Which ligament gives the best pasive stability at o degrees of shoulder abb?
**SGHL and CHL**
46
# shoulder
Which structures give active stability to the shoulder?
* RC muscles
* Scapulothorathic muscles:
* SA
* Deltoid
* Triceps
* Teres major
* Rhomboids
* Levator scapulae
47
# shoulder
The lower the negative LR...
the better it is
48
# shoulder
Shoulder muscles prone to **shortness:**
* Levator scapulae
* Pectoralis major and minor
* Suboccipitals
* Sternocleidomastoid
* Upper trapezius
* Scalenes
* Teres major and minor
* Subscapularis
49
# shoulder
Which 4 signs have a great positive likehood ratio for dectecting **RCT**?
(+LR 28)
* Age greater than 60
* ER weakness
* Positive drop arm
* Night pain
50
# shoulder
How does proximal humerus fx usually occurs?
trauma, FOOSH
51
# shoulder
Which ligament gives the best pasive stability at **45 degrees** of shoulder abb?
MGHL
52
# shoulder
What is the next adhesive capsulitis tx if after **6 months** of conservative mgmt (PT) there is no improvement?
manipulation under anesthesia
53
# shoulder
Weakness and atrophy in supraspinatus and infraspinatus may be due to what?
suprascapular nerve entrapment
54
# shoulder
which is the most common arthritic condition of the shoulder?
GHJ OSTEOARTHRITIS
55
# shoulder
What is the chance of Hill-Sachs lesion in an anterior dislocation?
recurrence?
* 35% of dislocations
* 80% of recurrent dislocations
56
# shoulder
What **MUST** the therapist check in a shoulder dislocation (can become a complication)?
* Nerve integrity, Axillary nerve
* vascular integrity, check radial pulse
57
# shoulder
How is an intrarticular fx of the scapula treated?
ORIF
58
# shoulder
Think instability/impingement for
younger patients especially overhead athletes
59
# shoulder
Point scale to rule in RCT:
* **0-1 = 42%**
* **2-3 = 68%**
* **4-5 = 91%**
* *Age \> 65 (2 points)*
* *ER weaknes (2 points)*
* *Night pain (1 point)*
60
# shoulder
Biceps load test:
* **Labral tear (Sp: 90%)**
* Examiner puts the shoulder in 120°shoulder AB and 90° elbow flexion
* Move the patient’s shoulder to end range ER
* Examiner should now resist elbow flexion
* +ve test is pain reproduction
61
# shoulder
a positive LR of 1 to 2 and
negative LR of 0.5 - 1.0
not good
A small and rarely important shift in probability
62
# shoulder
Objective examination includes:
1. Structural inspection
2. Screening exam (if there are radicular symptoms)
3. Movement Analysis
4. AROM
5. PROM:
* Joint mobility assessment: GHJ, STJ, SCJ, ACJ
6. Resistive test:
* MMT / MSTT
7. Muscle lenght if needed
8. palpation
63
# shoulder
What is the the "QuickDASH"
* A functional outcome measure
* **The higher the percentage the higher the disability**
* **0-100%**
64
# shoulder
What nerve can get injured in prox fractures of the humerus?
axillary
65
# shoulder
After **one month** of conservative mgmt (PT) if there is no improvement in adhesive capsulitis...
**1 injection of corticosterois is indicated**
66
# shoulder
How are 85% of prox humerus fx treated?
The other 15?
* closed means: sling + early motion
* Surgery: pins, traction, ORIF, joint replacement
67
# shoulder
What is likehood ratio?
combine sensitivity and specificity
68
# shoulder
Complications in shoulder dislocation:
* axillary artery and nerve damage
* may be an associated fx to the glenoid (ORIF)
* stiffness: loss of AB/ER
* Hill- Sacks lesion
69
# shoulder
MOI of AC sprains?
* Direct trauma
* FOOSH
70
# shoulder
Structures through subacromial space:
* Supraspinatus
* Subacromial bursa
* LH Biceps
71
# shoulder
A positive **Biceps Load II** test means that:
(in terms of 90% specificity)
* 90% sure they have a labral tear
* 10% chance to get a false positive
72
# shoulder
direction of joint mobilization to increase external rotation?
anterior
73
# shoulder
volleyball female player shows difficulty with external rotation. The MRI shows a cyst underneath the spine lat scapula:
may be spinoglenoid notch impigment
74
# shoulder
Think RCT for older individuals presenting with
night pain
75
# shoulder
Which ligament gives the best pasive stability at **90** degrees of shoulder abb?
**IGHL**
76
# shoulder
Post operative **Small RCT guidelines:**
* Sling 1-2 weeks
* Full PROM: 6-8 weeks
* Isotonics 8 weeks
77
# shoulder
Screening out RCT:
* No night pain (Sn 87.7)
* No arc of pain (Sn 97.2)
* No impingement signs (Sn 97.2)
* No weakness
78
# shoulder
True or false:
Anterior shoulder dislocations always causes Bankart lesions
**false**
79
# shoulder
Post operative **Med-large 2-5cm** RCT guideline:
* Sling: 4-6 weeks
* Full PROM: 8-10 weeks
* Isotonics: 10 weeks
80
# shoulder
which RC muscles are prone to shortness?
**subscapularis** and **teres minor**
81
# shoulder
Pt c/o L shoulder pain that does not change with rest. Activities/movements do not change symptoms
referred visceral pain from **heart** or **spleen**
82
# shoulder
Classification of irritability:
83
# shoulder
when does movement analysis occur during the examination test?
after screeening exam
before AROM
84
# shoulder
What happens in a GRADE I AC sprain?
Sling for how long?
Back to normal in how long?
* a simple stretching of the AC ligament
* sling 1-2 weeks
* 5-6 wks back to full competition
* (ACJ sprain, direct trauma or FOOSH)
85
# shoulder
when does the MMT test occur during the exam?
* after PROM
* before muscle lenght
86
# shoulder
What happens in a **GRADE III AC sprain**?
Surgery? Sling for how long?
Back to normal in how long?
* AC and CC ligaments completetly tear
* No surgery. Sling at least 1 month (4-6 wks)
* Rehab 6 months before back to normal
* Sometimes surgery required
87
# shoulder
What is a Hill Sachs lesion?
* Indentantion fx of the posterior humeral head
* casued by anterior dislocation
88
# shoulder
Sulcus sign:
* **Multidirectional instability**
* Grasps elbow and pulls down causing an inferior distraction force
* Examiner notes in cm distance between inferior acromion and superior humeral head
* +ve test is excessive movement
89
# shoulder
which are the 1st three steps of the examination process?
1. Review of pt reported materials: intake form, imaging
2. Observation
3. History
90
# shoulder
How would you differenciate a RCT from Pancoast's tumor in older individuals presenting with night pain?
In pancoast's tumor activities/movements do not change symptoms
91
# shoulder
Think labral injuries for...
repetitive overhead activities or trauma
92
# shoulder
Pt complains of pain ranges from posterior joint line to the insertion of the deltoid, RC muscle are intact, pain gets worse at night, **loss of motion** which has an bony end-feel
GHJ Osteorarhritis
93
# shoulder
What is FOOSH?
**Fall on Outstretched Hand**
94
# shoulder
Labral tears MOA:
traumatic or repetitive stress:
* FOOSH
* Repetitive: high eccentric activity of the biceps muscle during deceleration phase of throwing (peel-back mechanism)
95
# shoulder
How is a traumatic unidirectional dislocation that includes a Bankart lesion treated?
surgery
96
# shoulder
What is suprascapular nerve entrapment?
* Impigment of the suprascapular nerve in the suprascapular notch
* Weakness in supraspinatus and infraspinatus
97
# shoulder
Who may be prone to posterior dislocation:
* extremelly rare
* MOI: ad/ir
* **swimmers** when they hit the wall to turn
98
# shoulder
What is TUBS?
**Shoulder instability**
* Traumatic
* Unidirectional
* Bankart lesion (3-7 on the R shoulder 5-9 on the L)
* Surgery
All bankart lesions are treated with surgery
99
# shoulder
When does AROM occurs during the examination?
after movement analysis
before PROM
100
# shoulder
3 questions for differential diagnosis of the shoulder:
1. Are the patient’s symptoms reflective of a
* *visceral disorder**?
2. **From where** is the patient’s pain arising?
3. What has gone wrong with this person as a whole to cause pain?
101
# shoulder
Type III/IV SLAP associated with:
traumatic instabilities
102
# shoulder
direction of joint mobilization to increase abb?
inferior
103
# shoulder
Scapulohumeral rhythm:
* GHJ 120
* STJ 60:
* SCJ 30
* ACJ 30
104
# shoulder
* Elevated cytokine levels which cause inflammation.
* Inflammation eventually causes scarring of the rotator cuff interval, superior GH ligament and coracohumeral ligament.
* This leads to a limitation in all motion but mostly ER of the GHJ (capsular pattern)
**adhesive capsulitis**
105
# shoulder
short pect minor and lower trapezius weakness may create what movement of the scapula?
anterior tipping of the scapula
106
# shoulder
Which 3 shoulder special tests, when performed together, have a great positive likehood ratio for dectecting **subacromial impigment**?
* **Positive Hawkins Kennedy**
* **Positive Painful Arc**
* **Infraspinatus test**
* +LR 10.54
107
# shoulder
the higher the value, the better the chance to **rule in** the condition or pathology
**Specificity**
**SpIN**
108
# shoulder
Spinoglenoid notch impigment:
* difficul to diagnose
* may be confused with RCT
* supraclavicular nerve has already innervated the supraspinatus, therefore only the infraspinatues is affected (ext rota)
* volleyball players
* mostly female
* there may be a cysts
109
# shoulder
Shoulder muscles prone to **lengthen:**
* Middle and lower trapezius
* Serratus anterior
* Longus colli and capitis
* Supraspinatus
* Infraspinatus
* Rhomboids
110
# shoulder
In which type of labral tear should you avoid biceps contractions?
SLAP
111
# shoulder
Overhead activities change symptoms may be...
* impigment
* RCT
* Labral tear
* Multidirectional instability
112
# shoulder
Arm feels heavy after activities:
* vascular problem: arterial insuficiency
* aneurysm in axillary artery
113
# shoulder
Treatment of GRADE IV, V VI AC sprain?
(No need to know these)
* Surgical intervention
* Reconstruction
* 6 months and over
* Very rare
114
# shoulder
a positive LR of \> 10
and negative LR of less than 0.1
Generates large and often important shifts in probability
115
# shoulder
Think frozen shoulder for...
insidious onset, middle age females
116
# shoulder
O'Brien test:
* Labral tear primarily
* Could be a sign of AC pathology if pain is the AC area. If so:
* AC compression test
* Cross-Body Addcution test
* Patient: sitting
* Shoulder flexed to 90 and 10°of horizontal adduction
* IR the shoulder apply resistance **(auch, pain)**
* ER the shoulder apply resistance **(no pain, or less pain)**
* +ve test is pain/clicking with the shoulder in IR
117
# shoulder
Types of SLAP lesions:
which types have biceps tear?
* **Type I:** fraying of the superior labrum. May be treated conservatively
* **Type II:** superior labrum frayed, torn, and detachment of the biceps anchor
* **Type III:** bucket handle tear of superior labrum.
* **Type IV:** bucket tear of the superior labrum with extension into the biceps tendon. Part of the biceps anchor still intact
118
# shoulder
Apprehension/Relocation test:
* **Anterior instability**
* Patient: supine shoulder in 90° of AB
* Apply maximum passive ER of the shoulder
* +ve test is the patient showing signs of apprehension (guarding, scary, may or may not be pain)
* **Relocation part:** apply post force on the humeral head to provide stability, external rotation
119
# shoulder
Subject that have pain closer to end range of shoulder motion you should consider which joint as a pontential implicator?
Acromioclavicular joint
120
# shoulder
Crank test:
* **Labral tear**
* Pt supine: shoulder in 160 degrees AB
* Apply a compression force to the humerus and rotate the humerus repeatedly into IR/ER
* +ve test is pain and/or clicking
121
# shoulder
IMPINGEMENT/RC SPECIAL TESTS
* Neer Impingement Test
* Hawkins Kennedy
* ER Lag Sign
* IR Lag Sign
* Drop Arm
* Full Can
122
# shoulder
SLAP stands for
Superior Labral tear Anterior to Posterior
123
# shoulder
Yerganson test:
| (Sp: 86%, Sn: 26%)
* **biceps tendonitis**
* A negative result: 74% chance you got a false negative ("useless" Dr. M)
* Flex the elbow to 90° and the forearm pronated with the arm at the side
* The examiner should resist ER and supination
* **+ve test is pain reproduction**
124
# shoulder
Speed's Test:
| (Sp: 66%, Sn: 32%)
* Primarily biceps tendonitis
* Could be used for labral test
* Palapate bicepts tendon (may feel creep during the test)
* Resists shoulder flexion from 0-60 degrees
* +ve test is pain reproduced in the bicipital groove
125
# shoulder
Shoulder dislocation tx?
Reduction: traction or traction with ER
126
# shoulder
what is the chance of recurrence after a shoulder dislocation?
**60%** specially before 18 birthday
127
# shoulder
the higher the value, the better the chance to **rule out** the condition or pathology
**Sensitivity**
**SnOUT**
128
# shoulder
**High** irritability pain scale:
\> 7/10
129
# shoulder
Pain that occurs between 70 and 110 degrees of abduction is deemed a **painful arc**, and may indicate...
rotator cuff impingement, or tearing, or subacromial bursitis
130
# shoulder
Internal (Posterior) Impingement:
special tests?
* Overhead athletes
* AB/ER (cocking phase)
* Anterior instability
* **Internal Impingement Test**: Sn: 88% -LR 0.13, Sp: 96% +LR 8.2
* pt stands 90°shld AB 80°ER
* Examiner resists IR then ER
* +ve test \> weakness with IR
* **Jobe Relocation Test:**
* ****Posterior pain found upon overpressure to end range external rotation in the 90/90 position that is relieved with an posterior force would indicate posterior internal impingement.
131
# shoulder
The pain occurs due to compression of the supraspinatus and infraspinatus tendons by the posteriorly rotated greater tuberosity of the humeral head against the posterior/superior portions of the glenoid:
Internal (Posterior) Impingement
132
# shoulder
Pathologic contact between the margin of the posterior glenoid and the posterior tendons of the rotator cuff thatface the articular surface of the glenohumeral joint is known as
133
# shoulder
The chronic repeated compression or impingement can cause fraying of the undersurface of the supraspinatus tendon as well as some fraying of the superior labrum which can lead to ...
superior labrum anterior to posterior (SLAP) lesions
