Shoulder

Question 1

Define Sensitivity

Answer 1

Sensitivity: Ability of a test to correctly identify patients with an injury. Consequently, if it is negative, the patient probably truly does not have the condition (SNOUT)

-True positives / True positives + False negative

Question 2

Define Specificity

Answer 2

Specificity: Ability of a test to correctly identify patients without an injury. Consequently, if it is positive, the patient probably truly does have the condition (SPIN)

-True negatives / True negatives + False Positives

Question 3

Describe the Break test (Manual Muscle Testing Strength)

Answer 3

Position joint, stabilize proximal segment, instruct patient to hold position as examiner attempts to move the distal segment opposite the patient’s effort. Gradually build resistance (3-5 sec.) until slightly exceeding the muscle’s force.

Results:

1. Strong without pain: Normal
2. Strong with pain: Muscle/tendon lesion
3. Weak without pain: Nerve dysfunction or muscle/tendon rupture
4. Weak with pain: Serious injury (fracture, unstable joint, etc.)

Question 4

Describe the different grades of the Manual Muscle Tests (Muscles Engaged with ROM)

Answer 4

Normal= 5/5 – Full resistance
Good= 4/5 – Some resistance (unable to hold maximum resistance)
Fair= 3/5 – Movement against gravity only
Poor= 2/5 – Movement, but not against gravity
Trace= 1/5 – Can fire muscle, but no movement (palpate some contraction)
Zero= 0/5 – Cannot fire muscle, completely inert

Question 5

What are the Musculoskeletal Neurovascular exams and special tests?

Answer 5

• Sensation
• Reflexes
• Pulses
• Capillary refill

Special tests
Tinel’s, Phalen’s, [Adson’s]

Question 6

Define Dermatomes

Answer 6

Dermatomes - area of skin in which sensory nerves derive from a single spinal nerve root

Question 7

Define Myotomes

Answer 7

Myotomes - group of muscles innervated by a single spinal nerve root

Question 8

Define Reflexes

Answer 8

Reflexes - involuntary and nearly instantaneous movement in response to a stimulus

Question 9

Describe the Adson’s Test

Answer 9

• Evaluation of Thoracic Outlet Syndrome
• Technique: Patient breathes deeply (Neck extended) –> Chin turned toward affected side –> Repeat test with chin to opposite side
• Interpretation: Decreased Radial Pulse + Distal extremity pain reproduced –> suggests inter-scalene compression

Question 10

What are the different Grades of pulse amplitude

Answer 10

0      Absent, unable to palpate
1+	Diminished, weaker than expected
2+	Brisk, expected
3+	Increased
4+	Bounding

Question 11

Describe Synovial joints

Answer 11

• Joint articulations are freely mobile
• Bones do not touch & are separated by synovial cavity
• Assoc. with bursae
• Disc-shaped synovial sacs that allow muscles & tendons adjacent to a joint to glide over each other
• E.g. shoulder, knee

Question 12

Describe Cartilaginous joints

Answer 12

• Slightly movable
• Bony surfaces separated by fibrocartilaginous discs
• E.g. intervertebral joints, pubis symphhysis

Question 13

Describe Fibrous joints

Answer 13

• No movement
• Fibrous tissue or cartilage holds bones together
• E.g. cranial sutures

Question 14

Describe Synovial joints – Spheroidal (ball & socket)

Answer 14

• Wide-ranging movement in several planes
• Wide range flexion, extension, abduction, adduction, internal & external rotation
• E.g. shoulder, hips

Question 15

Describe Synovial joints – hinge

Answer 15

• Motion in one plane
• Flexion, extension
• E.g. elbow, foot, interphalangeal joints of hands

Question 16

Describe Synovial joints - condylar

Answer 16

• Movement of 2 articulating surfaces, condyles are convex or concave
• E.g. knee, TMJ

Question 17

Describe The shoulder “girdle”

Answer 17

• made up of 3 bones, 3 joints, 3 muscle groups
• 3 bones (scapula, humerus, clavicle)

-3 joints
Glenohumeral
Sternoclavicular
Acromioclavicular

-3 muscles
Scapulohumeral group
Axioscapular group
Axiohumeral group

Question 18

Describe the Scapulohumeral muscular group

Answer 18

• Extends from scapula to humerus
• Includes muscles inserting directly on humerus, the SITS muscles of the rotator cuff
• Rotate shoulder laterally

Question 19

Describe the Axioscapular muscular group

Answer 19

• Attaches the trunk to the scapula
• Includes trapezius, rhomboids, serratus anterior, & levator scapulae
• Pull shoulder backwards (rotate scapulae)

Question 20

Describe the Axiohumeral muscular group

Answer 20

• Attaches the trunk to the humerus
• Includes pectoralis major + minor, latissimus dorsi
• Rotate shoulder internally

Question 21

What are the Special Tests/script for a hurt Acromioclavicular Joint?

Answer 21

Cross Body Test
AC Shear Test (AC Resisted Extension Test)
Compression test

“Fell on adducted shoulder while biking, or getting hit into the boards in Hokey”

Question 22

Describe Joint Laxity vs. Instability for the Glenohumeral Joint

Answer 22

Joint laxity: Can be Multidirectional
-Born flexible and voluntary or …
Involuntary: Acquired laxity from Trauma = Pain & Dead arm

Instability: A pathological condition linked to dissociation, producing pain.
-Can be Unidirectional:
Anterior instability (95% of Dislocations)
Posterior instability

Question 23

What are the Anterior GH Instability Tests?

Answer 23

Apprehension test
Relocation test
Release test

Question 24

What are some Secondary Injury to Anterior GH Dislocations?

Answer 24

Bankart lesion: Inferior-anterior labrum tear

Hill Sachs Lesion: Defect of humeral head

Question 25

Describe Pathomechanics

Answer 25

Bony restraints are minimal and the forces that can be generated far exceed the ability of the static restraints.

Question 26

What is the Script for a Labrum Lesion?

Answer 26

Complains of pain with overhead movements. (+) Biceps Load II test. (-) Yergason’s test. (+) Jerk test.

Question 27

Describe Shoulder Impingement Syndrome

Answer 27

Common to have anterior instability and posterior hypomobility (stiffness).

Question 28

What is the Script for a Subacromial Impingement Syndrome (SAIS)

Answer 28

``` Complains of pain with over-head movements. (+) Modified Hawkins test. (+) IR Resisted Strength Test. (+) Apprehension test. (+) Posterior capsule stiffness. ```

Question 29

Describe SAIS Tissue Determination

Answer 29

- Biceps traction test. - Resisted shoulder abduction - (at 10°abduction) with and without GH distraction.

Question 30

Describe Internal Impingement

Answer 30

Deep fibers of the supraspinatus or infraspinatus against the superior or posterior glenoid labrum and limbus or rim. Secondary to GH instability or repetitive throwing

Question 31

What is a good clinical test for Internal impingement?

Answer 31

Perform anterior apprehension / relocation test. | (+) if posterior shoulder pain with apprehension and decrease with relocation.

Question 32

What is a Common tear location for a Rotator Cuff?

Answer 32

Begin at supraspinatus insertion and expand between supraspinatus and infraspinatus (Intratendinous)

Question 33

Describe Rotator Cuff Disease:

Answer 33

- Degenerative, not overuse. - Usually on the articular side with a poor blood supply. - Uncommon before 40 yrs. of age - Seems associated with “heel” type acromion (Type III) - Prominence of hook caused by poorly functioning rotator cuff, making the shoulder rely on the coracoacromial arch for stability and an increased load placed on the coracoacromial ligament causing a traction spur.

Question 34

Describe the External Rotational Lag Sign

Answer 34

- With shoulder at 20° scaption & 90° elbow flexion; shoulder is externally rotated near end range. - The inability for patient to hold the external rotation is a positive sign for lag.

Question 35

Describe the Drop arm test

Answer 35

- Ask patient to abduct arm to shoulder level - If the patient cannot hold the arm fully abducted at shoulder level, the test is positive - A positive drop arm test suggests a rotator cuff tear Supraspinatus tendon rupture = Patient unable to fully abduct the arm

Question 36

Describe Adhesive Capsulitis Pathomechanics

Answer 36

- Cause of this arthrofibrosis is unknown. - Limited glenohumeral motion in all planes with pain - Immune system response = Fibroblasts lay down collagen as a thick nodular band or fleshy mass with no inflammation.

Question 37

Describe Adhesive Capsulitis Injury Mechanism

Answer 37

1. Primary Ideopathic - Insidious onset – pain restriction followed by gradual stiffness with less pain. Related factors include, diabetes, hypothyroidism. Most common in females 40 – 60 years. 2. Secondary Trauma or immobilization

Question 38

Describe the phases of Adhesive Capsulitis

Answer 38

Freezing phase (2-9 months) Limitation in movement & pain. Frozen phase (4-12 months) Plateau Thawing phase (5-26 months) Begin to restore movement & diminishing pain

Question 39

What test if used for Adhesive Capsulitis

Answer 39

Distension in PER test

Question 40

Describe Frozen shoulder (adhesive capsulitis)

Answer 40

- Joint capsule thickens & tightens around the joint restricting movement - Patients aged 50-70 - History - Prolonged immobilization (e.g. after surgery) - Diffuse, dull, aching pain - Progressive restriction of ROM - Usu. No localized tenderness - Course usually chronic

Question 41

Describe a Biceps tendon rupture

Answer 41

- Can rupture at origin or insertion (Origin more common) - Biceps muscle then shortens & becomes spherical -Tears, ruptures, fractures usu due to injury or trauma