UE - Shoulder Pathology Flashcards
(101 cards)
1
Q
Subjective exam systematic approach
A
- how old are you?
- what were you doing at onset?
- what is your chief complaint
- aggravating/easing factors?
- radiating or radicular complaints
- patient reported outcome measures
- develop differential diagnoses
- body chart
2
Q
What are two questions you always ask in subjective exam?
A
- how old are you?
- what were you doing when you got hurt?
3
Q
What is a patient reported outcome measure you can always use?
A
PSFS
Patient specific functional scale
- patient lists three troublesome activities and rates difficulty from 1-10
4
Q
What is an UE specific patient reported outcome measure?
A
DASH
5
Q
Objective exam systematic approach
A
- point to pain
- clear joints above and below
- neuro screen
- observe area (deformity/atrophy)
- quantity and quality of motion
- strength assessment
- special testing
- palpation
6
Q
What are three series ordered for shoulder x-rays?
A
- anteroposterior view (trauma series)
- scapular “y” lateral view
- axillary view
7
Q
anteroposterior x-ray view
A
-neutral, IR, ER
- good view of prox humerus and lateral clavicle, AC joint, upper/lateral scapula
8
Q
scapular “y” lateral view
A
- prox humerus fracture or dislocation
- acromial types - chronic subacromial pain
9
Q
axillary view
A
“armpit view”
- inferosuperior projection
- GH dislocation, lenoid fossa, coracoid process view
10
Q
What are three special tests for the cervical region?
A
spurlings, quadrant, and cervical compression
11
Q
What 3 things does a neuro exam assess?
A
strength, reflexes, sensation
12
Q
Cervical radiculopathy
A
- in our scope of practice
- nerve root issue
- lower motor neuron signs: hyporeflexia, weakness, bilateral weakness
- treatments based on relieving inflammation
13
Q
Cervical myelopathy
A
- not in scope of practice
- central cord compression
- upper motor neuron signs: hyperreflexia, balance impairment
14
Q
What are the 5 criteria for cervical myelopathy?
A
- over 45
- gait ataxia
- positive inverted supinator test
- positive hoffmans
- babinski sign
15
Q
What are the terminal branches of the brachial plexus and their root levels?
A
M (567)
A (56)
R (56781)
M (56781)
U (81)
16
Q
What are the two different types of thoracic outlet syndrome?
A
- neurogenic
- vascular (arterial or venous)
17
Q
What are the common sites of compression for thoracic outlet syndrome?
A
- sternocostovertebral space
- scalene triangle
- costoclavicular space
- coracopectoral space
18
Q
sternocostovertebral space
A
- between spine (post), 1st rib (lat), and sternum (ant)
- where a pancoast tumor would form
19
Q
scalene triangle
A
- between ant/mid scalene and clavicle
20
Q
costoclavicular space
A
- between clavicle and 1st rib
- caused by heavy weight on shoulder and shoulder descent (age/posture)
21
Q
coracopectoral space
A
- between pec minor and rib cage
- caused by tight pec minor, overhead activities, anatomic oddness, slouching
22
Q
What are some special tests for thoracic outlet syndrome?
A
roo’s, adson’s, wright, costoclavicular test
23
Q
Is vascular or neurogenic more serious?
A
vascular - medical emergency
neurogenic - idea area most likely at fault
24
Q
What are some treatments for thoracic outlet syndrome?
A
- inflammation control
- posture/ergonomic education
- activity specific biomechanics
- active rehab (mobility, strength, endurance)
- TAILOR REHAB FOR SPECIFIC IMPAIRMENTS
- 1st rib mobilization
25
Why is the SC joint almost always dislocated from a significant traumatic event?
- significant ligamentous support
- one of the LEAST DISLOCATED JOINTS
26
direct sc joint trauma leads to...
posterior displacement
can be life threatening
27
indirect sc joint trauma leads to
anterior displacement
- more common, most often from fall on lateral clavicle, can be treated by PT
28
What are the 3 types of sc sprains?
type one - mild sprain, pain with motion
type two - subluxation with movement
type three - dislocation
29
sc joint sprain treatments
type three - send to ER
otherwise:
- reduce inflammation (activity mod, short immobilization, ice)
- reduced motion, strength, endurance
- consider SC joint mobilization
- return to sport considerations (depends on sport)
30
_________ % of clavicle fractures are midshaft fractures
80
31
What diagnosis can a midshaft clavicle fracture mimic?
AC sprain
32
nonoperative or surgical treatment of a midshaft clavicle fracture depends on what?
amount of shortening (<2cm) and displacement (is it separated too much to make a callus?)
33
What is our main goal with treating a midshaft clavicle fracture?
- educate our patient
- restore function
- prevent nonunion
34
nondisplaced midshaft clavicle fractures are treated __________
nonoperatively
35
What are the treatment controversies with displaced midshaft clavicle fractures?
- treatment preference based on provider seen
- rate of malunion or nonunion
- excessive shortening of the clavicle
- return to sport timeframe
- surgery comes with risk of complication
- slight increased risk of nonunion without surgery
36
Two ways to get AC joint issues
- atraumatic degenerative changes
- fall on tucked shoulder "separation"
37
What are the three ligaments of the AC joint?
acromioclavicular
coracoclavicular
coracoacromial
38
What are the two parts of the CC lig?
- conoid
- trapezoid (most lateral)
39
Ways/tests to diagnose AC joint
- chief complaint/body chart
- plain films
- diagnostic injection
- cross arm adduction
- active compression test
- paxino test
- AC shear
40
3 important rockwood classifications
degree and direction of shoulder displacement:
type 1- mild AC sprain
type 2 - tear AC lig
type 3 - tear AC and CC lig/sup clavicle displacement
41
Zanca view x-ray
useful for seeing cc lig disruption. >50% widening from otherside seen as sprain
42
AC sprain treatment grade 1 and 2
- activity mod/taping
- short period of immobilization
- ice/NSAIDs/isometrics/maintain pain free ROM
- considered manual techniques
43
AC sprain treatment grade 3
- try nonoperative first
44
AC sprain treatment grade 4,5,6
surgical eval
45
AC joint arthrosis
"hurts"
degenerative change at the AC joint
46
causes of AC joint arthrosis
- related to previous trauma
- repetitive use
- may be insidious onset
- can progress to osteolysis of the joint
47
signs of AC joint arthrosis
- similar pain to AC joint injury
- no separation deformity
- inflamed or enlarged AC joint
48
treatment for AC joint arthrosis
- rest and education
- impairment based rehab
- injections (diagnostic and theraputic)
- distal clavicle excision
49
postop considerations of ac joint
- understand purpose of surgery
- understand def of failure
- respect sling time
- progress based on surgeon!
50
Issue with sling usage for AC injury?
- scapula moves inferiorly
51
complications with AC reconstruction
- loss of reduction *careful during postop rehab*
- coracoid or clavicular fracture
52
What is the most mobile joint in the body?
shoulder
53
great mobility = inherent _________
instability
54
static support of shoulder?
bone, ligament, labrum
55
dynamic support of shoulder?
RC, biceps, delts, pec major, lats
56
What is the primary issue after shoulder dislocation?
instability
57
95% of shoulder dislocations are...
anterior inferior dislocation
58
common anatomic injuries of dislocated shoulder
bankart tear - ant/inf labrum
hill-sachs lesion - posterior humeral head
59
true or false? instability can be measured
false, instability is a feeling reported by the patient
60
management of shoulder instability depends on...
- degree of anatomical injury
- demands of the patient (ex - contact sport)
- resultant instability versus laxity
61
What ligament is most tight when arm is by your side?
superior glenohumeral lig
62
what ligament is tight in the apprehension position?
inferior glenohumeral lig
(ant. band - bankart lesion)
63
What predicts poor response to rehab for shoulder instability?
- structural involvement
- age at first dislocation
- contact athletes
- recurrent instability (past injury)
64
TUBS
unstable shoulder
T = traumatic
U = unidirectional laxity
B = bankart lesion
S = surgery
65
AMBRI
unstable shoulder
A = atraumatic
M = multidirectional laxity
B = bilateral
RI = rehab
66
shoulder subluxation
shoulder pops out of socket but goes back in on its own
67
shoulder dislocation
joint pops out of socket and requires manual reduction
68
Beighton criteria
measures for joint laxity
69
2 types of surgical management for shoulder instability
- soft tissue procedures
- boney procedures
70
soft tissue procedures for shoulder stability
- bankart repair
- capsular shift
71
boney procedures for shoulder instability
- indicated for significant bone loss
- recurrence after soft tissue procedures
- latarjet - coracoid transfer
- remplissage for engaging hill-sachs lesions
- allograft for large hill-saches lesion
72
important things to ask pt with shoulder instability during eval
- age, onset, gender, sport, position
- number of instability events
- subluxation vs dislocation
- initial treatment to date/imaging?
- axillary nerve commonly impaired
- apprehension and relocation test
- sulcus sign - SGHL, inf. instability
- patient goals
73
PT management for shoulder instability
- postop: respect healing time, avoid ABER position
- nonop. management: rest/protection/prevent recurrence
- address dynamic stabilizers
- return to sport considerations
74
How common are posterior shoulder dislocations?
2-10%
75
What MOI is most common for posterior shoulder dislocations?
FOOSH (flexed, adducted, IR)
contact athletes, cycling, electrocuted, seizures
76
avoid excessive __________ ___________ during rehab for post. shoulder dislocations
posterior loading (pushup, planks)
77
What are the Neer stages of impingement for subacromial pain?
stage 1 - young, no tears or surgery
stage 2 - 25-40, scarring may require subacromial decompression
stage 3 - over 40, may have RC tear, may need RC repair
78
What structures are involved in subacromial impingement?
restricted space between acromion and HH
bursa, long head of biceps, and surpraspinatus tendon
79
What changes are related to developing subacromial pain?
- acromial shape: type 3 has small link
- subacromial spurring
- AC degenerative changes
- bursal thickening
- humeral elevation
80
What does a typical patient with subacromial pain look like?
- over 40
- general atraumatic shoulder pain
- painful arc of elevation 60-160
- point to lateral arm/middle delt for pain
- must rule out RC tear first
- must rule out impingement tests
- then exam AC joint
- then examen biceps tendon
81
PT plan of care for subacromial pain?
- ACTIVITY MODIFICATION IS A MUST
- reduce inflammatory response
- improve glenohumeral rhythm
- educate patients expectations
82
surgical management of subacromial pain
- diagnostic injection (diagnostic/therapeutic - should be combined with PT)
- subacromial decompression (debriedment, bursectomy, release CA lig)
- LH biceps tendonosis
- AC joint resection
83
Subacromial pain treatment controversy
-sham surgery trail (no diff between surgery and control)
- most improve with rehab despite structure
- some improve with no specific treatment
84
Subacromial pain should use a __________ approach for rehab
staged
85
Between what 2 structures does shoulder impingement occur?
greater tuberosity of HH and posterosuperior aspect of glenoid
- contact is normal, only pathologic if painful
86
Shoulder impingement GIRD
Glenohumeral
Internal
Rotation
Deficit
- increased ER with repetitive throwing
- contracture of post band of IGHL
- increases posterior superior contact
87
Treatment to internal impingement
- posterior capsule stretching
- addressing SICK scapula and RC strengthening
- activity modification
88
SICK Scapula
Scapular malposition
Inferior medial angle protrusion (winging)
Coracoid pain
K scapular dyskinesia (wing/tip in abnormal ways)
89
SLAP tear
superior labral ant/post tear
90
internal impingement clinical presentation
- young overhead athlete
- post pain with apprehension test
- GIRD
- SLAP tears
- SICK scapula
91
Non-operative treatment for internal impingement
- posterior capsule stretching
- address SICK scapula, RC strengthening
- activity modification (remove from play)
92
operative treatment for internal impingement
- articular sided RC tears
- posterior superior labral tears
- anterior laxity or instability
- posterior capsular contracture
93
What are the 3 main functions of RC?
- centers HH in glenoid
- humeral rotation
- humeral head depressor
94
Supraspinatus
- suprascapular innervation
- prone to tears
- tests: Abd MMT, open can, drop arm, Jobe empty can
95
Infraspinatus
- suprascapular innervation
- strong ER
- tests: ERLS, resisted ER with arm at side
96
Teres minor
- axillary innervation
-ER
- tests: ERLS, hornblower
97
Subscapularis
- upper/lower subscap innervation
- IR
- tests: lift off, belly press, bear hug
98
What is adhesive capsulitis
- capsular inflammation and fibrosis
- capsular pattern of motion restricted (ER most restricted, AROM and PROM also restricted)
99
What causes adhesive capsulitis
- Diabetes
-Thyroid disease
- can occur after injury or surgical scarring
100
How to treat adhesive capsulitis
- joint mobilization
- pain free resistance training as appropriate
*-injection therapy with motion exercises
*- motion exercise and education
101
Is surgery a good way to treat adhesive capsulitis?
no!
- hydrodilation: fill capsule with fluid to get inside stretch
- Manipulation under anesthesia then PT
- lysis of adhesions
