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Flashcards in Shoulder (CPG & SR+MA) Deck (46):
1

Adhesive capsulitis - risk factors

  • Type 1/2 DM
  • Thyroid disease
  • Age 40-65 (51-55 peak)
  • Female
  • immoblization, MI, trauma, autoimmune

 

2

High Irritability

  • Pain  = High levels of pain (7/10)
  • Night/resting pain = consistent
  • Disability = High (ASES, DASH, PSS)
  • Pain before end range (AROM/PROM)
  • AROM <

3

Moderate Irritability

  • Pain = moderate (4-6/10)
  • Night/resting pain = intermittent
  • Moderate disability (ASES, PSS, DASH)
  • Pain AT endrange (PROM/AROM)
  • AROM = PROM

4

Low Irritability

  • Pain = minimal  (<3/10)
  • Night/resting = none
  • Disability = minimal (DASH, ASES, PSS)
  • Pain only with OP PROM
  • AROM = PROM

 

5

Adhesive capsulitis stages

  1. Early loss ER
  2. Freezing (loss all ROM  3-9 months)
  3. Frozen (9-15 months)
  4. Thawing (15-24 months)

6

Subacromial impingement tests

(Hegedus & Beiderwolff)

subacromial impingement

  • Hegedus >= 3/5 +LR 2.93, -LR 0.34
    • Neer Sn 72% / Sp 60%
    • Hawkins-Kennedy test Sn 79% Sp 59%,
    • painful arc Sn 53% Sp 76%,
    • empty can Sn .30, Sp .74
    • infra MMT
  • Beiderwolff
    • HK, painful arc, infraspinatus MMT 
      • 3/3 +LR 10.5
      • 2/3 +LR 5.03

 

 

 

7

Beiderwolff 2013

Algorithm

 

 

Objective 

  • IRRST 90o ABD, 80o ER
    • positive = IR << ER, + intra-articular pathology
      • capsule instability, lesions, internal impingement
    • negative = IR >> ER, +RC pathology
      •  
    •  Sp .96 Sn .86
    • +LR 22.0 -LR 0.13
  • If normal (IR 60% of ER), extra-articular

8

Beiderwolff 2013

Subjective

Rotator cuff tendinopathy OR

sub-acromial impingement

RC tendinopathy / Sub-acromial impingement

  • anterior/lateral pain
  • painful arc
  • night pain

9

Beiderwolff 2013

Subjective 

Rotator cuff tear

RC tear

  • anterior/lateral pain
  • compensatory shrugging
  • constant achiness
  • wake during sleep
  • >40

10

Beiderwolff 2013

Anterior instability

Anterior labrum

Bankart

(subjective)

 

Anterior instability, Bankhart, anterior labral

  • anterior pain, apprehension/pain in ER/ABD
  • trauma
  • hx of subluxation, "dead arm"
  • clicking, locking

 

11

Beiderwolff 2013 

Posterior instability

Labrum

Posterior instability, labrum

  • deep posterior pain
  • apprehension/pain with
    • pushing and/or
    • ADD and/or 
    • CKC position
  • hx posterior/inferior trauma
  • clicking/locking/clunking

12

Beiderwolff 2013

SLAP subjective

SLAP

  • deep shoulder pain, 
  • clicking, locking, clunking
  • pain w/ eccentric deceleration and/or loading of biceps

 

13

Beiderwolff 2013

LHB subjective

 

LHB tendinopathy

  • anterior pain, TTP LHB
  • pain w/ ecentric deceleration and/or loading of biceps

14

Beiderwolff 2013

AC joint subjective

AC joint 

  • superior joint pain
  • pain w/ end range elevation, ADD
  • TTP AC joint
  • step-off
  • MOI

15

ASES

  • Scale 0-100 (100=no pain/disability)
  • Pain & function subscales 50 each
  • MCID 6.4 points
  • MDC 16.0 points
  •  

16

DASH

  • 0-100% (higher = more disability)
  • 30 questions, 5 point likert
  • SEM (4.6-7.6 points)
  • MDC 12.2 (10.7-12.8 points)
  • MCID 10.2 points

17

SPADI

  • 13 items (pain/function)
  • 0-50 points for each section
  • 0-100 total score (100=worse)
  • MCID 10 points
  •  

18

 Adhesive capsulities - Interventions

  • CSI + MT - strong
  • Education - moderate evidence
  • Stretching w/respect for irritability level - moderate
  • Modalities - weak
  • Mobilization - weak (perhaps moderate?)
  • MUA - weak

19

Rule in /out diagnosis of 

Adhesive capsulitis

  • Rule in
    • 40-65
    • gradual onset, progressive worsening ROM
    • limited ADLs
    • GHJ PROM/mobes limited ER worse than all
    • GH ER decrease w/ABD 45-->90
  • Rule out if 
    • PROM normal
    • PROM increases ABD 45-->90
    • GH arthritis
    • ULTT reproduces sxs

20

Rule in / out diagnosis of:

Shoulder stability and movement coordination impairments

OR

dislocation or sprain/strain

  • Rule in
    • <40
    • hx of shldr dislocatin
    • excessive GHJ accessory motion
    • apprehension flex/abd and/or ER
  • Rule out
    • No hx of dislocation
    • GHJ motion limitations
    • no apprehension

21

Rule in / out diagnosis of:

shoulder pain & muscle power deficits / rotator cuff

  • Rule in
    • sxs developed/worse with repeitive overhead or acute trauam
    • midrange catching or arc of pain
    • MMT midrange reproduce pain
    • rotator cuff msucle weakness
  • Rule out 
    • resistive tests pain free
    • rotator cuff normal strength
    • signficant loss PROM

22

Imaging

  • Adhesive capsulitis
    • arthrographic < 10-12mL
    • MRI
    • US (rotator cuff interval)
  •  

23

GHJ Ligamentous stability

  • Inferior GH ligament
    • Anterior band - resists anterior translation (90o ABD, full ER)
    • Posterior band - resists posterior translation
  • Middle GH ligament
    • anterior translation 0-45o ABD
    • limits ER at 0o ABD
  •  Superior GH ligament
    • inferior translation (ADD or 0o ABD)

24

AC joint ligamentous stability

  • Conoid coraclavicular
    • anterior & superior rotation / displacement
  • Trapezoid coracoclavicular
    • horizontal & vertical displacement
  • Acromioclavicular and joint capsule
    • posterior displacement & rotation

25

Types of rotary cuff impingement

  • Primary
    • mechanical beneath coracoarcomial arch
    • (abnormal structural characteristics)
  • Secondary
    • relative decrase in space by micro-instability of GHJ / scapulothoracic
  • Posterior
    • elevated/ER
    • undersurface of tendons
    • associated with anterior instability

26

Hegedus 2012

SLAP tears

SLAP tears

  • Rule in and rule out
    • Passive distraction AND active compression
      • Sn .70, Sp .90 +LR 7.00 - LR .11
  • Rule out SENSITIVE:
    • Relocation Sn .52
  • Rule in SPECIFIC
    • Rule in with compression rotation AND apprehension AND speed SP .92, + LR 3.13
    • Yeragasons Sp .95
    • Compression-rotation test +LR 2.81
    • Passive distraction Sp .80%, LR+ ≥ 5.0

 

27

Hegedus 2012 - OA/adhesive capsulitis/RC tears

OA/Adhesive capsulitis/RC tears

  • Shoulder shrug Sn .80 , LR− ≤ 0.20)

 

28

Hegedus 2012 - other high Sn / Sp

Subscapularis tear Sn/Sp

  • belly-off and modified belly press tests for bony instability 

bony apprehension test for bony instability

bony abnormality

  • olecranon-manubrium percussion test

SLAP (Sn/Sp)

  • passive compression for a SLAP lesion

RC tear (Sn/Sp)

  • lateral Jobe test for rotator cuff tear

29

Abdulla et al 2015 (OPTIMa) SR

Exercise for

subacromial impingement &

other soft tissue shoulder

Variable duration SIS

  1. Supervised strengthening = greater short-term imporvement in pain/disability vs. wait list
  2. supervised/home-based strengthening/stretching = greater short-term improvement in pain/disability vs. no treatment

Persistent duration SIS

  1. supervised & home-based strengthening = similar outcomes as surgery
  2. home-based heavy load eccentric training does not add benefit to home-based RC strengthening & PT

Variable duration low-grade non-specific shoulder pain:

  1. supevised strengthening & stretching leads to similar short-term outcomes as CSI or multimodal care

30

Desjardin et al 2015 JOSPT

Manual Therapy for RC tendinopathy SR and MA

Overall MT + exercise reduces pain (sig not clinically)

  • MT compared with placebo or other
    • Decreased pain  - pooled effects statistically, not clinically, important (VAS 1.2 95%CI 0.08,1.6)
  • MT alone compared with placebo
    • Decreased pain, statistically, not clinically important (VAS 1.0, 95% CI 0.6,1.4)
    • Improved function 1 RCT (sig not MCID)
    • Not necessarily ROM
  • MT+EX
    • Decreased pain (VAS 1.0, 95%CI 0.7,1.4)

31

Yu et al (OPTIMa) 2015 PTJ

Effectivess of Passive Physical Modalities for shoulder pain SR

low-level laser more effective than placebo or ultrasound for SIS

shock-wave therapy more effective than sham for persistent shoulder calcific tendinitis

32

Dong et al 2015 PRISMA SR Medicine

Treatments for SHoulder Impingement Syndrome

excellent for EARLY stage

  1. Exercise PLUS
  2. Kinesio taping
  3. Acupuncture 

Consider if exercise not option:

  1. Standard ASD vs. open arthroscopic bursectomy & open sub-acromial decompression
  2.  

33

Goldgrub et al 2016 SR

Effectiveness of Multimodal Care for management of shoulder soft tissue injuries 

  1. Patients with variable duration shoulder pain should be managed with supervised strengthening and stretching (HEP)
  2. Little evidence that multi-modal care provides superior effectivenss compared with individual interventions for SIS or non-specific shoulder pain

34

Chester et al 2013 BMC MSK

Predicting response to PT treatment for MSK shoulder pain SR

Two prognostic factors:

  • duration of shoulder pain
    • longer ASW poorer outcome
    • shorter ASW better outcome 
  • baseline function
    • high baelin disability ASW poor functional outcome
    • (vice versa not explored)
  • age 
    • older = worse
  •  

 

35

Scapular kinematics

healthy/pathologic

(Ludewig et al JOSPT 2009)

Grp   Healthy     imping/RTC       GHJ instab      Adhesive Cap

1o       Up rot        Dec up rot          Dec up rot       Inc up rot

2o      Post tilt      Dec post tilt              -                          -

3o      ER /  IR       Inc IR                  Inc IR                        -

36

Shoulder force couples

  1. Deltoid (superior) + infra/supra & teres minor (inferior); supraspinatus  --> compressive
  2. Lower trap / serratus anterior + upper trap / levator scap = upward rotation
  3. subscap + infraspinatus / teres minor = depression and compression (GHJ --> glenoid)

37

3 types of scapular dyskinesis

(SICK)

  1. Anterior tilt
  2. IR
  3. Downward rotation
  • Scapula malposition
  • Inferior medial border prominence
  • Coracoid pain & malposition
  • dysKinesia of scapular movement

38

Rotator cuff exercises

(Ellenbecker & Cools BJSM 2010)

 

  • Ellenbecker & cools
    • Initial
      • Sidelying ER 
      • Prone EXT (with ER)
    • Next
      • Prone horizontal ABD
      • Prone ER with scap retraction
    • Supraspinatus
      • Prone horizontal abduction (90o ABD) (NOT empty can)

39

Scapular exercises

  • Serratus strengthening / retraining
    • low row, inferior glide, lawnmower, robbery
  • Upper trap reduction
  • Posterior capsule stretching
  • Pec minor stretching
  • t-spine extension

40

Supraspinatus Tendinopathy 

(Beiderwolff & Hegedus)

  • Beiderwolff
    • ER lag sign
      • Sn 13% Sp 88% +LR 15.5,34.5 -LR 0.2,0.32
  • Hegedus
    • Supraspinatus tear 
      • >39,painful arc,popping/clicking
        • >= 2/3 Sn .75, Sp .81, -LR .32, +LR 3.82
        • = 3 Sn .38, Sp .99, -LR .63 + LR 32.20
    • Any RC tear (rule in)
      • Age >65 & infra MMT & night pain
        • +LR 9.8, 
        • -LR .54

41

Infraspinatus tear

Hegedus & Beiderwolff

  • Beiderwolff
    • ER lag sign (- -rule out, ++rule in) 
      • Sn . 69-.98, Sp .98
    • Dropping sign (- - - rule out, +++ rule in)
      • Sn 1.00, Sp 1.00
  • Hegedus
    •  

42

Hegedus 2012

Anterior Instability

Anterior Instability

  • Rule in AND rule out with
    • Apprehension AND relocation 
      • Sn. 81, Sp .98, -LR .19, +LR 19.68

 

43

Primary impingment

Primary impingment

  • abnormal mechanical relationship b/t RC & coracoacromial arch
  • Hx
    • > 40, anterio/lateral upper arm
    • unable to sleep on side
  • Obj
    • dec ROM/strength
    • +Neers, HK
    • AC arthrosis
    • worse with IR & ABD >90
  •  

44

Secondary impingement

Secondary impingement

  • narrowing of sub-acromial space due to GH or ST instability
  • History
    • typically younger & overhead
    • "arm going dead"
  • Obj
    • GH instability ri & ro (apprension & relocation)
    • +full/empty can
    • scap dyskinesia/winging/abnml motion
    • tight posterior GH capsule

45

46

RC and ST exercises

(Reinold et al JOSPT 2009)

  • Supra - full can, prone full can
  • Infra/TM - sidelying ER, prone ER 90 ABD, ER w/towel
  • Subscap - IR @ 0/90 ABD, IR diagonal
  • SA - pushup+, dynamic hug, SA 120o
  • LT - prone full can, prone ER 90 ABD, prone H ABD@90oABD w/ER, bilat ER
  • UT - shrug, prone row
  • rhomboid, levator scap - prone row, prone H ABD@90ABD w/ER, prone EXT w/ER