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80 terms

CONA II: Shoulders

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Anterolateral Impingement
supraspinatus mm, subacromial bursa
Anteromedial Impingement
subscapularis mm
Posterolateral Impingement
posterior labrum, infraspinatus, teres minor
Fall on outstretched arm
Clavicle fx; posterior dislocation; biceps, suprapinatus, or labral tear
Land on top of shoulder
AC separation, distal clavicle Fx
Arm abducted & extended at impact
Anterior dislocation
GH locks & "clicks" back in place
Labral tear
Worse with lifting weights and/or heavy objects
Osteolysis of the distal clavicle, labral tear
Overhead positions
Impingement syndrome
Biceps, supraspinatus, bursa
Is then neck & shoulder pain timing similar
Osteoarthritis (DJD), myofascial pain syndrome (MFPS)
Associated neck pain with trauma
Cervical sprain/strain, burner, brachial plexus injury
More stiffness than pain
Unreduced GH dislocation
Did the stiffness get worse after a few weeks of pain in shoulder
Adhesive capsulitis
Concurrent pain in other joints
Rheumatoid arthritis, Ankylosing spondylitis, Pseudogout (CPPD,HADD), DJD
Visceral complaints same time as the shoulder complaint: GI complaints
Referred pain from gallbladder
Visceral complaints same time as the shoulder complaint: Pulmonary complaints
Infection, tumor, etc.
Visceral complaints same time as the shoulder complaint: Cardiac complaints
Myocardial infarction
Location: Anterior, Traumatic
Fracture, GH dislocation, subacromial bursitis, capsular sprain, strain/rupture of the long head of biceps, labral tear
Location: Anterior, Non-traumatic or overuse
Impingement syndrome, subcoracoid impingment, biceps tendinitis, subacromial bursitis, subscapularis tendinitis, subluxation
Location: Lateral, Traumatic
Contusion, suprapinatus sprain/rupture
Location: Lateral, Non-traumatic or overuse
Impingement syndrome, deltoid strain, suprapinatus strain/rupture, visceral referral
Location: Superior, Traumatic
AC separation, distal clavicle fracture
Location: Superior, Non-traumatic or overuse
Osteoarthritis (DJD) affecting the AC joint, osteolysis of the distal clavicle
Location: Posterior, Traumatic
Scapular fracture, posterior dislocation
Non-traumatic or overuse
Posterior impingement, infraspinatus/teres minor mm strain/tendinitis, posterior deltoid/triceps mm strain
Trauma and pain in all ranges
Dislocation/fracture/rupture
Pain at midrange of abduction (70 -110°)
Impingement syndrome
Restriction of active ROM only
Muscle/tendon
Restriction of active & passive ROM
Capsule, bone
Inability to hold/lower the abducted arm
Rotator cuff
When combined, found to be as sensitive as MRI for labral tears
Crank test
Load and shift test
Apprehension test(s)
Empty can test
Jobe's test
Biceps tendon
Speed's
AC separation/sprain
Sudden pain from fall on outstretched arm or fall on top of shoulder, lifting heavy objects
Type 1 AC separation
Some tearing, no instability
Conservative care
Type 2 AC separation
Rupture of AC lig, unstable
Conservative care
Type 3 AC separation
Rupture of AC & coracoclavicular ligs (conoid and trapezoid), unstable
Conservative care with Kenny Howard sling (2-3 weeks) then rehab (if not recovered, then send for surgical consult)
Type 4 AC seperation
Posterior displacement of distal clavicle
Type 5 AC separation
Inferior acromion
Type 6 AC separation
Conjoined biceps and coracobrachialis tendon
Adhesive Capsulitis
Pain in external rotation and abduction
Usually over 40 y.o.
Females > Males
History of pain lasting for weeks > gradual stiffening of the shoulder as the pain diminishes
Patients note a dramatic decrease in shoulder ROM
Adhesive Capsulitis associated conditions
Cervical spondylosis, hypothyroidism, and diabetes are related conditions
Osteoarthritis
Insidious onset of achy pain and loss of ROM
Loss of active and passive ROM
Should be considered in all elderly or postraumatic patients
Traumatic Instability
Pain or weakness with overhead activity or in apprehension position
History of shoulder dislocation
CLASSIC BANKART LESION
Labral avulsion from the glenoid rim with capsular stripping from the scapular neck
BONY BANKART LESION
Labral avulsion with bone from the anterior glenoid rim and capsular stripping from the medial scapular neck
Bankart type 1
0.5 cm avulsion
Bankart type 2
1.0 cm avulsion
Bankart type 3
1.5 cm avulsion of capsule
Bankart type 4
fx of glenoid rim
Chronic Labral Tears
Pain and clicking with rotational movements, but ROM is usually full
History of trauma or instability or laxity
Non-Traumatic Instability
"Born loose", symptomatic due to poor biomechanics of the shoulder coupled with overuse or trauma
Passive care directed at symptoms, rehab focusing on shoulder mechanics and strength
Avoid positions that stretch the capsule
T.U.B.S. ("Torn Loose")
Traumatic
Unidirectional
Bankart Lesion
Surgery should be considered
A.M.B.R.I
Atraumatic
Multidirectional Instability
Bilateral Laxity
Rehabilitation Helps
Inferior Capsule Tightened
Surgical tightening of rotator interval
The rotator interval is a triangular portion of the shoulder capsule which lies between the supraspinatus and subscapularis tendons
Impingement Syndrome: Humeral tuberosity
supraspinatus
Painful arc 45~120
GH impingement
Painful arc 170~180
AC pathology
Rotator Cuff Tear
History of chronic or acute trauma
Complain of pain with overhead activities or unable to raise the arm
Supraspinatus: Most commonly torn tendon
Signs like impingement, may have weakness
Biceps tendon tear
Bunching up of the muscle
(+) Transverse humeral ligament test
Weak and painful = partial tear
Weak and painless = full tear (with or without neurologic damage)
Approx 50% of all ruptures occur thru the tendon of the long head > Some strength will remain
Proximal Biceps Tendon Rupture (Long Head)
From resisted forced flexion (eccentric)
May be secondary to repetitive cortisone injections
Discoloration
Palpable and visible defect with "popeye" muscle
Weakness on supination (Yergason's)
Surgery for young; conservative care for elderly
"SLAP" Lesion
Detachment lesion of the superior aspect of the glenoid labrum, which serves as the insertion of the long head of the biceps
A traction injury, such as catching oneself falling, is a common cause
A fall on the outstretched hand ("F.O.O.S.H."), or repetitive activities (pitching) may predispose to this injury
Normal Anatomy: in one half of patients, the biceps attaches to the supraglenoid tubercle (other half: biceps attaches to the superior labrum)
Rotator cuff pathology is present in 40% of patients with "SLAP" lesions
Pain with overhead activities mimicking impingement syndrome (be careful)*
Type I "SLAP"
Fraying and degeneration of the superior labrum (with firm attachment to the glenoid), normal biceps; usually degenerative in nature
Type II "SLAP"
Detachment of superior labrum and biceps insertion from the supra-glenoid tubercle (this is the most common type of SLAP lesion; may resemble a normal variant)
Type III "SLAP"
"Bucket handle-type" tear (biceps anchor is intact)
Type IV "SLAP"
Vertical tear of the superior labrum, which extends into biceps; may be treated w/ biceps tenodesis if more than 50% of the tendon is involved
Tendinitis & Bursitis
Usually severe pain that is worse with most ROM (insidious, related to overuse, or result of a trauma)
Distinct location of palpatory tenderness
Treat as any other tendinitis/bursitis
Sling for support, but do not leave it on for extended periods of time, and encourage shoulder exercises to tolerance
Subacromial Bursa
A large synovial membrane which is adherent to undersurface of coracoacromial ligament, acromion, & deltoid laterally (floor is adherent to rotator cuff & greater tuberosity)
Envelops proximal humerus (facilitates gliding of proximal humerus under coracoacromial arch)
Calcific Tendinitis
Usually not seen until the 4th decade
Diabetic patients are more likely to develop asymptomatic rotator cuff calcium deposits
> 30% of insulin-dependent diabetics had tendon calcification (< 10% of non-diabetics have this lesion)
Osteolysis of the Clavicle
Diffuse pain felt at the distal clavicle
Patient is often a young, serious weightlifter (as opposed to an old, casual weightlifter?)
Complaints of pain with bench pressing, overhead pressing, and/or dips
Cause unknown (usually related to AC trauma resulting in resorption of the distal clavicle)
Pain with ABD >90, ortho exam is often unremarkable
AC spot view (widening of joint space, subchondral defects)
Ergonomically modify to narrow grip, avoid dips
Surgery= acromioplasty
Little Leaguer's Shoulder
Proximal humerus pain in an adolescent that occurs primarily with throwing hard
Salter Harris Type I (due to rotational stress on the growth plate)
Palpable tenderness
Pain on resisted external rotation and supraspinatous test
Diagnosed by x-ray—widened humeral physis
Suprascapular nerve
Sensory: Supraspinatous area (Supraclavicular C3~C4), (Infra = Sup scap)
Supraspinatus/infraspinatous mm atrophy
Secondary to suprascapular notch trauma
Axillary (circumflex) nerve
Sensory: Lateral deltoid area (C5~C6)
Deltoid/teres minor mm atrophy
Secondary to anterior humeral dislocation
Radial nerve
Sensory: Dorsal surface of hand (Radial: C5~T1, Radial superficial: C6~C8)
Elbow/wrist extensor mm atrophy
Secondary to humerus fracture
Musculocutaneous nerve
Sensory: Lateral forearm (C5~C7)
Elbow flexor mm atrophy (biceps)
Secondary to forced elbow hyperextension or repetitive pronation
Long Thoracic N
C5~C7
Serratus anterior mm atrophy ("scapular winging")
backpack
Spinal Accessory N
Trapezius mm atrophy
backpack
Clavicle Fractures
usually middle third
Humerus Flap fracture
occurs in the great tubercle secondary to relocation of an anterior dislocation
Myositis Ossificans
Heterotopic bone formation secondary to trauma to sheath covering muscle or bone
Refer
Fracture is discovered
Ligament/tendon rupture is suspected
instability that would likely result in permanent disability
Non-reduced dislocation
Infection
Tumor