1
Q
deltoid
A
abduction (after initiated by supraspinatus), axillary n.
2
Q
supraspinatus
A
initiates abduction of humerus
N: suprascapular n.
most common cause of intrinsic shoulder pain!
source of pain
- Originates on superior aspect of scapula
- Inserts on greater tubercle of humerus
- Passes through narrow area between acromion and head of humerus
suceptible to repetitive motion: baseball, house painters, UPS — often pinched by abduction
- only protected by the subacromail (sub-deltoid bursa)
3
Q
infraspinatus
A
lateral rotation of humerus, suprascapular n.
4
Q
teres minor
A
lateral rotation of humerus, axillary n.
5
Q
teres major
A
medial rotation of humerus, lower subscapular n.
6
Q
subscapularis
A
medial rotation of humerus, upper and lower subscapular n.
7
Q
rotator cuff mm?
A
SITS: subscapularis, supraspinatus, infraspinatus, teres minor
supraspinatus is the most common to have problems!!!
- Weakness of the cuff muscles allow upward migration of the humeral head during use which irritates the supraspinatus tendon and/or muscle from impingement on the acromion.
- This results in tendinopathy which can lead to a tear. Acute tears can happen with more forceful injury mechanisms.
- Disuse atrophy of supraspinatus or deltoid seen, crepitus or grating noise when lifting arm.
- In complete supraspinatus tear, when abducting arm the shoulder shrugs upward from the effort of the deltoid in early abduction. There is a positive drop arm test = inability to hold 90 deg abduction when arm released.
8
Q
serratus anterior
A
scapula protraction, fixes scapula to thoracic wall
long thoracic n.
9
Q
biceps brachii
A
flexes forearm, supinates hand (most powerful supinator)
musculocutaneous n.
10
Q
brachialis
A
flexion of forearm (most powerful flexor)
musculocutaneous n.
11
Q
brachioradialis
A
flexion of forearm, radial n.
12
Q
coracobrachialis
A
flexion and adduction of humerus
musculocutaneous n.
13
Q
triceps brachii
A
extend forearm - radial n.
14
Q
extrinsic causes of shoulder pain? neuro?
A
cervical nn. root compression (C5,6)
supraspinatus nn. compression
herpes zoster
cervical spine disease
15
Q
abdominal/cardio/thoracic causes of shoulder pain?
A
abdominal: hepatobiliary disease, diaphragm irritation (ectopic pregnancy)
CV: MI, axillary vein thrombosis, thoracic outlet syndrome
thoracic: upper lobe pneumo, apical lung tumor, PE
16
Q
intrinsic shoulder path?
A
Pain with specific movement or palpation Stiffness Weakness/loss of function Atrophy Pain Instability
17
Q
supraspinatus test?
A
empty can
OR
resist elbow abduction at 90 degrees
18
Q
subscapularis test
A
have patient rotate forearm medially against pressure – resist wrist going in
or
“lift off test”
19
Q
infraspinatus/teres minor test?
A
patient rotates forearm laterally against resistance – resist wrist going out
or
place patients arms flexed 90 degrees with thumbs up - provide resistance as patient presses outward
20
Q
drop arm test
A
patients arm is abducted to 90, gently push on arm - pain shows rotator cuff tear
21
Q
disuse atrophy of supraspinauts
A
hear crepitus/grating when raise arm
22
Q
complete supraspinatus tear?
A
when abducting arm the shoulder shrugs upward from the effort of the deltoid in early abduction. There is a positive drop arm test = inability to hold 90 deg abduction when arm released.
23
Q
impingement
A
- Can cause a rotator cuff tear.
- Night pain common, gradual onset. Atrophy of superior and posterior muscles possible.
- Localized tenderness not common, but pain, crepitus or sudden pain while abducting the arm common.
Test: Hawkins and Near impingement signs.
- tip of acromion becomes a jammed up region
- Weakness of the rotator cuff can lead to superior subluxation of the humeral head when the shoulder is abducted beyond 90 degrees, predisposing to impingement syndromes.
Surgical treatment options often necessary for satisfactory results - take tip of acromion off
24
Q
“Hawkin’s impingement sign”
A
shows if there is impingment of the subscapularis mm, d/t the acromion process
flex patients shoulder and elbow to 90 degrees, palm facing down
- then rotate arm internally by applying upward force at the elbow, and downward force at forearm
- this compresses the greater tuberosity against the coracoacromial libmament
25
Neer's impingement sign
press on the scapula, raise patients arm--- this compresses the greater tuberosity of the humerus against the acromion
26
acriomioclavicular separation
"fall on the tip of the shoulder" - results in driving the shoulder down, doesn't take clavicle with it
involve both AC and coracoclavicular ligaments
5 grades of separations.
Tender right over AC joint:
- visual inspection confirmation typically at or above type 3
- Surgical care threshold varies, more type 4-6. - Otherwise conservative care: physical therapy
27
arthritis of shoulder
= loss of joint space, loss of cartilage
- results in loss of BOTH active AND passive ROM, generally tender w/ crepitus
- xray is best for imaging
- can occur from longstanding unrepaired rotator cuff tear, often pushing up into the acromion
28
adhesive capsulitis
- same process as "frozen shoulder joint" : have long standing loss of generalized ROM
- muscle atrophy, significant loss of BOTH ACTIVE AND PASSIVE ROM - generally tender,
- c/o stiffness and crepitus
- can't move anything, progressive arthritic changes --> atrophy and tenderness is diffuse
- MRI is the most helpful form of ddx: helps see things in soft tissue when there is bone around (xray is best for acute trauma)
- MRI shows thickening and fibrosis
- DM is significant risk factor, worse pain at night
tx: PT ROM tx, surgical release/adhesion reduction in severe cases
29
Bursitis
- Trauma, repetitive motion. Tender
- hikes the ball of joint on acromion, often makes the bursa inflamed/angry
- Good clue between bursa and tendonitis is pain difference with active vs passive ROM.
- Can inject then test ROM and strength again to help discern etiology.
- would use lidocaine (short acting, quick onset)
- if are still weak after the tx, then know it is maybe a mm. problem
- Ultrasound can help, but diagnosis is primarily by clinical exam and therapeutic challenge (injection) -- can use landmarks for injection
30
SLAP
= superior labrum anterior to posterior tear
- most common in "throwing athletes", or those who do lots of overhead work
- also caused by preventing a fall by grabbing something or lifting something heavy suddently that engages the biceps
- pain at superior portion of glenoid
- Do O'brien's test
- do MRI for define it
Types 1-4 depending on severity:
- Anterior pain, clicking or reproduction of pain in certain positions, particularly abduction and external rotation. (resisting this position may bring it out). Frequently accompanied by other lesions. Examine for all.
- Treatment often conservative for non-professional athletes. Surgical recovery 6-12 months
31
"Lidocaine injection test" pain after an injection at subacromial bursa
- Patients with a rotator cuff tear will have persistent weakness despite pain relief with injection
- those with rotator cuff tendonopathy will have normal strength in association with pain relief.
- Patients with a frozen shoulder will have persistent loss of range of motion.
- Dramatic reduction in pain and improvement in overall shoulder function after injection of the subacromial bursa effectively rules out a significant glenohumeral joint process.
- The lidocaine injection test in the subacromial bursa is indicated when the history and physical examination cannot effectively exclude an underlying rotator cuff tendon tear, a developing frozen shoulder, or concurrent involvement of the acromioclavicular (AC) joint.
32
O'Brien's test
tests for glenoid labrum integrity or SLAP tear
flex arm to 90 degrees, adduct across chest, internally rotate with thumb pointing down, then push down on arm
pain is positive for labral tear (SLAP)
- different from crossover test d/t internal rotation of the arm w/ downward pressure
33
crossover test
adduct the arm across the patients chest to strain the AC joint - pain indicates problem with the AC joint
34
arthrography
contrast injection into joint w/ serial x rays - fluoroscopy largely replaced by MRI
35
tests
if traumatic use xrays first!
36
rotator cuff tendinopathy findings
very common
>age 40, pain increases with reaching, freq. repeptivie activity at or above shoulder
findings:
- subacromial tenderness
- pain with apley scratch test
- normal passive ROM
- normal strength, but pain with abduction/external rotation
- pain with impingement testing: neer/hawkins tests
37
rotator cuff tear findings
- often middle aged or older
| - same as rotator cuff tendinopathy but weakness presents with resisted abduction and external rotation
38
adhesive capsulitis findings
past hx of rotator cuff tendinopathy/diabetes or immobility
c/o of decreased motion without or with pain
findings: significant decrease in ROM of both active and passive
39
glenohumoral osteoarthritis findings
past hx of shoulder trauma
decrease in ROM both active and passive
40
biceps tendinopathy findings
pain increases when carrying objects with elbows bent/lifting overhead
findings: biccipital groove tenderness, pain with resisted elbow flexion/supination
41
biceps tendon rupture findings
sudden increase in shoulder pain with "popeye" deformity (prominent ipsilateral distal bicep)
findings:
obvious biceps deformity, pain with resisted elbow flexion/supination
42
AC injury findings
recent fall onto adducted arm
find: AC joint tenderness, pain with adduction of injured arm, dray shows clavicle elevation
43
AC osteoarthritis findings
focal AC joint pain w/out recent trauma
find:
AC joint tenderness, pain with adduction of injured arm
44
shoulder instability findings?
<40 y/o, athletes w/ overhead sports
see apprehension, relocation and release tests positive
45
subscapular burisitis findings?
poor mm. development, frequent reptitive to and fro motion, direction pressure (ie backpack) are common causes
find: superiomedial scapular border is tender
46
scapular stabilizer mm. weakness findings
sederntary, works at desk, poor posture with rounded upper back
have abnormal motion, wall push off shows scapular winging
47
posterior pain
think SI joint, lumbar, unusually true hip joint pain
48
anterior/groin pain
this is actual hip joint pain!!
| - osteonecrosis, sepsis, fracture, synovitis
49
lower anterior thigh pain
could be referred true hip pain, upper femur, femoral neck, lumbar radiculopathy
50
if niether direct pressure or ROM reproduces hip pain
think hernia, lower abdominal pathology or reffered pain from lumbar
51
laternal tenderness with palpation
bursitis
52
lateral pain w/ paresthesia
think meralgia paresthetica -
53
trochanteric bursitis
- comes in with "hip pain" -
- exaggerated or abnormal movement of gluteus medius and TFL over greater trochanter.
- Gait and all that can affect it key area of investigation.
- Lateral hip pain. Just posterior superior to point of trochanter.
- If chronic, the bursa will fibrose and lose it’s ability to provide a more frictionless surface for movement.
```
If suspecting a trochanteric bursitis, what issues or history do you want to know?
Lumbar muscle tightness
Leg length discrepancy
Knee or ankle arthritis
Varus/valgus stance or gait
Do they wear orthotics?
Gait asymmetry for any reason.
```
" new job walking a lot, many stairs, orthotics broke 6 months ago cannot afford to replace "
confirmation: local anesthetic block
54
osteoarthritis of hip
- common, often a problem occured over time
- low grade inflammatory arthritis b/c its irritated, when stop using it the fluid gel up and result in pain in the morning-- "it hurts a lot in the morning, have to get it moving throughout the day"
Activity pain, occurring at night when more advanced.
Groin, aggravated by movement more than palpation.
Key exam feature is restricted abduction; internal rotation limitation and pain, limited flexion and morning stiffness (geling phenomenon) all can occur
abnormal Patrick/Fabere test - isolates the hip joint - pt. lying supine, hip is flexed, abducted, externally rotated
- press with hand down on knee, with other hand on the opposite ASIS
confirmation: standing AP pelvis xray
55
Meralgia paresthetica
"trucker's nerve pinch"
lateral femoral cutaneous nerve susceptible to impingement, especially as it courses under inguinal ligament.
Sensory only, paresthesia/burning upper anteiror/ lateral thigh.
If weakness or DTR changes seen, cannot be or be limited to this nerve!!! way deeper!
Consider bursitis referred pain or lumbar radiculopathy
56
osteonecrosis
also known as aseptic necrosis, avascular necrosis or osteochondritis dissecans.
Compromised vascular supply to the femoral head - decreased circulation into head of femur (similar to scaffoid which is one way supply)
Joint destruction (collapse) within 3-5 years common if untreated.
Groin pain, weight bearing and motion induced most common.
Rest pain and night pain also seen, and would be in more progressive cases.
- limping, tenderness over anterior hip, abnormal patricks
Early diagnosis needed, often missed.
most common causes?
90% of cases are d/t corticosteroids and excessive alcohol use!!!
" prior MVA 2 years ago back and hip injury. "
ddx test: AP xray of pelvis, or aspiration of hip --- MRI is most sensitive
57
occult hip fracture
Severe pain to light weight bearing,
Intolerable hip rotation ROM.
- refusal to bear weight on the hip
- abnormal patrick's fabere
- MRI needed, plain xray not sensitive enough, don't show up
- best thing to do is stablize it, and wait, in 7-10 days a normal individual will start to heal and see white line in the area of tenderness in xray
- heals just fine! but needs to rest it
58
referred hip pain
from lumbar and SI joint common.
Suspect:
- Whenever groin pain accompanied by back pain
- Symptoms extend beyond the knee
- Paresthesia is present and
- Direct exam of the hip is unremarkable.
59
tests for hip pain?
Tests -----
Xray: trauma, boney issues suspected, re-xray suspected occult fracture
MRI: Occult fracture particularly when close to soft tissue.
CT: better bone detail in image, so occult fracture in long bones, more isolated bony regions
US: not quite there yet.
Bone scan: Tc-99, sensitive, but specificity about 40%, lots of false +.
Inspection:
- Gait, palpation, ROM (squatting duck walk, internal/external rotation, faber)
- Significant pain at ROM end point strong indicator:
osteonecrosis, occult fracture, acute synovitis, metastasis
60
Fabere test?
tests the hip joint/ SI pathology
: F-AB-ER-E: flex, abduct, externally rotates, extends the leg in a figure 4, then gently push knee to table. If painful, indicates hip, psoas or SI problem.
61
vascular insufficiency of hip?
tests: doppler study
diminished dorsalis pedis and posterior tibial pulses, delayed capillary fill time
62
lumbar radiculopathy
straight leg maneuver causes radicular pain, limited flexion and lateral bending, abnormal lower extremity neuro exam
tests: CT or MRI showing nerve compression
3 major sign that indicate MRI "pain, weak, atrophy"
63
Osgood-Schlatter
AKA:
= Tibial Tuberosity Avulsion
= Osteochondritis of tibial tubercle
- Apophysitis of tibial tubercle at the insertion of the patellar tendon
= inflammation of the patellar ligament at the tibial tuberosity. It is characterized by a painful lump just below the knee and is most often seen in young adolescents. Risk factors include overuse (especially in sports involving running, jumping and quick changes of direction) and adolescent growth spurts.
- pretty benign, have bone growth from the upward pull of the quadriceps on the patella on the tibia - tubercle may become very prononced as have callus laid down from stress
- kid with knee pain, lots of sports, in the lower anterior region - its palpable and reproduceable - will find all ligaments around knee are ok!
- kid presents with anterior knee pain that increases gradually over time may cause a limp and is exacerbated by exercise
Clinical presentation:
- Age 9-14 y/o very active in sports w/ rapid growth spurt
- Clinical diagnosis, radiograph not needed unless individual circumstances need to investigate other causes
Stress Fracture
Bone Tumor
Quadricep tendon avulsion
- Self limited: pain control, continue activity, leg strengthening through physical therapy
- complete avoidance of activity is NOT recommended, inactivity can decondition the area- playing with pain is permited!!!
- PT to strengthen the quads
- Knobby knee can be permeant
atypical features that need to be evaluated?
- erythema over tubercle: may think osteomyelitis
- acute onset of pain - think avulsion fracture
- pain at night - think tumor
64
hip strain vs. hip sprain?
hx" caught herself from falling on ice, has hurt ever since
```
sprain = ligaments
strain = muscle or tendon
```
65
osteoporotic fracture of hip?
would look for "dowager's hump" - humped over older female
would be postemenopausal, fair, thin heavy smoker, FMH +, maybe some minor trauma prior
66
32 y/o male with right shoulder pain.
HPI: insidious onset 3 months ago, constant strong ache daily and will always worsen at night. Superior and lateral. Will radiate toward his neck when severe. Pain between 4-8/10. Worsens with overhead work, Celebrex (celecoxib) has helped, and ices at night to calm it down.
Right hand dominant. Slowing his work productivity, important to find more effective treatment. You have not seen him for 9 months.
PMH: DM-2, HTN; No surgeries or hospitalizations. Concussion from several falls snowboarding. Sees Chiropractor regularly
Meds: Celebrex 200 mg qd
Januvia (sitagliptin) 50 mg PO qd
Prinizide (prinivil+HCTZ) 20/25 PO qd
Ginseng herb daily
Allergies: NKDA, none to env or food
SocH:
House painter for 6 years. Prior snowboard racing age 17-23. More painting work in the last year.
Gen: Denies unexpected weight change, unusual fatigue, fever, night sweats.
MSK: no joint swelling or redness. Right shoulder occasionally feels warm. Denies neck pain or prior known injury. No myalgia. Denies other acute joint pain. Unable to easily fully abduct right arm.
Neuro: 3 episodes of tingling in his lateral upper arm only. No hand or forearm weakness. Right shoulder feels weak he thinks only from pain. Denies tremor, difficulty with handwriting, numbness/tingling in other areas. No shooting pain episodes. Denies memory or mood issues, no significant headaches.
= impingement
67
look at questions at end of slide show!!!
do it now. f
PCM IV: Test 1
flashcards
Decks in class (4)
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