Shoulder

*Immobilization in sling and/or AC brace *Ice *Anti-inflammatories *NSAIDs *Restrict reaching over head and across the chest *Avoid direct pressure to joint *Type III may need surgery

*Acromioclavicular Injury: Treatment*

*partial disruption of AC joint capsule *no joint instability *TTP AC joint, swelling, pain with ROM *no displacement seen on X-ray (normal on weighted film)

*Acromioclavicular Joint Injury- Separation Grade I:

*Complete tear of AC ligament, partial tear or stretching of CC ligament *TTP at AC joint, swelling, possible protrusion of the clavicle and AC joint laxity *on X-ray, distal clavicle lies about inferior margin of the acromion but below superior margin *AC gap evident on weighted X-ray (MEASURABLE DISPLACEMENT!)

*Acromioclavicular Joint Injury- Separation Grade II:

*complete disruption of the AC and CC ligaments *very TTP over AC joint, pain with ROM, +swelling, significant joint laxity, outer edge of clavicle is prominent superiorly *plain films slow distal clavicle at or above the superior margin of the acromion

*Acromioclavicular Joint Injury- Separation Grade III:

*Inflammation of one or more of the tendons of the rotator cuff *tends to occur as a result of chronic subacromial impingement, progressive tendon degeneration, traumatic injury, or a combination of these S/Sx: (similar to impingement) -Pain aggravated by reaching, pushing, pulling, lifting, positioning the arm above the head -Pain when lying on the affected side -Pt RUBS DELTOID when describing pain! PE: -TTP over RTC tendons and GT -Decreased ROM and strength in abduction -May have + empty can -May have + apprehension test Tx: -Restricted motion (careful here!) -ICE -NSAIDs -PT MORE PAIN IN SHOULDER ("RUBBING SHOULDER") THAN IMPINGEMENT (MORE ARM-BASED PAIN)

*Supraspinatus/Rotator Cuff tendonitis*

Allen test for thoracic outlet syndrome Squeeze ulnar and radial arteries- positive if blood flow returns within 7-10 seconds

What is this test and what is it for?

Apprehension Test -Rotator cuff tendonitis (may be positive) -Glenoid labrum injury (discomfort) -Multidirectional instability (apprehension w/ extremes) -Glenohumeral dislocation (very positive!!!)

What is this test and what is it for?

The Roos test for thoracic outlet syndrome The pt repeatedly clenches and unclenches the fists while keeping the arms abducted and externally rotated (palms forward and upward). The elbows are brased slightly behind the frontal pain. The test is positive when sx's are reproduced with this maneuver.

What is this test and what is it for?

Tinel's test for thoracic outlet syndrome (also for carpal tunnel). *Lightly tap over median nerve. Positive = tingling in the thumb, index, and middle finger

What is this test and what is it for?

Hawkins test, used to test for Impingement Syndrome

What is this test and what is it used for?

Neer test ("arm near ear"), used to test for RC Impingement Syndrome

What is this test and what is it used for?

*Bankart lesion*

What is this?

*Glenohumeral dislocation* (general)

What is this?

A-P shoulder X-ray for dislocation

What is this?

AC joint injury/separation

What is this?

Axillary view of shoulder XR for dislocation

What is this?

PE: -AC joint enlargement/deformity -AC joint tenderness -Pain aggravated by forced adduction and/or downward traction -AC joint laxity with downward traction- widening may be palpable and/or visible with high grade separation. The acromioclavicular (AC), coracoclavicular (CC), and the coracoacromial (CA) ligaments which hold the acromion, clavicle, and corocoid bones toegther can be sprained, partially torn, or completely disrupted from... *Overuse: reaching across the chest and over the head *Trauma- results from falling onto tip of the shoulder with arm tucked at side. *Repeated strain or injury to be supporting ligaments may ultimately progress to osteoarthritis of the AC joint. Dx: Based on H & P; X-ray (confirm degree of separation and classification, identify osteoarthritis)

*Acromioclavicular joint injury/separation*- suspends arm and scapula (GENERAL)

aka "STINGER"- transient brachial plexopathy *Upper extremity nerve injury which commonly results form impact to the neck and shoulder -Result of traction or compression of brachial plexus or C5 or C6 nerve roots -Typically transient -Commonly recur S/Sx: *Presentation: -Hx of trauma/collision to head or neck -Pain radiating down one upper extremity -+/- numbness, weakness, paresthesias -Discomfort frequently resolves within 1-2 minutes PE: *+/- atrophy or asymmetry of neck *+/- depression and atrophy of deltoid and/or supraspinatus *TTP over spasm *Check for focal cervical vertebral tenderness- r/o Fx *Bilateral manual muscle testing may elicit weakness in muscles innervated by injured nerves *RED FLAGS- bilateral Sx, focal cervical tenderness, focal neuro deficits *Dx: based on Hx, further testing not needed unless underlying injury suspected -X-ray -MRI *Tx: -Address predisposing factors -Correct strength deficits -Enhance protective equipment *Prevention: -Technique training -Protective equipment

*Brachial plexus injury*

S/Sx: -Hx of significant injury -Pain at fracture site -Unable to lift arm due to pain PE: -Decreased ROM, children may refuse to move arm -Visible and/or palpable deformity -TTP over fracture site -Grinding sensation when arm is abducted -Check skin! -r/o nerve injury! Dx: Hx, PE, X-ray Tx: Pain meds and immobilization (figure 8 brace? sling?), PT for slow progression to gentle ROM- ORIF only on special cases Eti: *Newborns- due to birth trauma *Adolescents/young adults- MC fractured bone in children (trauma) *Elderly- osteoporosis and falls **80% occur in the middle 1/3 of the clavicle, 15% in lateral 1/3, 5% involve medial end)**

*Clavicle Fracture*

Presentation: *Similar to rotator cuff tendonitis -Chronic shoulder pain -Stiffness -+/- TTP over shoulder *Deltoid insertion TTP- DELTOID PAIN!!!!!! *Diffuse TTP -Decreased ROM: active AND passive *Limited reaching *Limited rotation *Greatly decreased active and passive ROM with pain at extremes of ROM -Special tests: *Apley scratch test *NFL touchdown sign *Idiopathic loss of both active and passive ROM *Reversible contraction of joint capsule *In long-standing cases, adhesions may form from between the joint capsule and humeral head = ADHESIVE CAPSULITIS Dx: indicated to insure normal bony anatomy and rule out bony pathology; XR may show decreased bone density in the humerus Tx: -Treat underlying process -PT!!!! -Gradually stretch lining of glenohumeral joint *Acute- exercise, NSAIDS *Chronic- corticosteroid injection, surgery

*Frozen shoulder- Adhesive capsulitis*

S/Sx: -PAIN -Swelling -Bruising -Decreased ROM -Decreased sensation upper extension -Upper extension weakness Physical exam: -Arm held in guarded position -TTP especially over anterior shoulder -Decreased ROM and strength -Decreased sensation -++++++ apprehension test *Anterior dislocation (90%) -Caused by forced external rotation and extension -Must have appropriate x-rays to diagnose -Recurrent dislocation typically associated with two types of lesions *BANKHART- anterior injury associated with tear of the glenoid labrum off the anterior glenoid rim *HILL-SACHS- a compression fracture of the articular surface of the humeral head posterolaterally *Other associated injuries: avulsuion of GT, AXILLARY NERVE INJURY! Dx: based on H & P- humeral head may still be minimally displaced on X-ray Tx: ICE, ICE, ICE! -immobilization 2-6 weeks in internal rotation; PT for gentle, progressive ROM *If closed reduction indicated... -N/V check before AND after reduction -Post reduction XR to confirm placement

*Glenohumeral dislocation- anterior dislocation*

*Result of same mechanisms that produce rotator cuff injury *Often seen on athletes who engage in repetitive overhead activities *Sx: deep shoulder pain, catching sensation, instability, crepitus *PE: discomfort with apprehension position *Dx: MRI or Arthrogram *Tx: try conservative then refer

*Glenohumeral dislocation- glenoid labrum injury*

*Secondary to fall onto arm with shoulder with arm adducted and internally rotated -Common in pts with Hx of recent SEIZURE or ELECTROCUTION -Arm held in internal rotation -Reverse Hill-Sachs lesion

*Glenohumeral dislocation- posterior dislocation*

S/Sx: (similar to RC tendonitis) -Increasing shoulder pain with no Hx of trauma -Difficulty lifting above head, combing hair, opening fridge, holding gallon of milk -PAIN RADIATES DOWN ARM (right up to insertion of deltoid!) -NIGHT PAIN!!! PE: -Pain with abduction -Pain with flexion and internal rotation -Subacromial tenderness -Normal shoulder ROM -Preserved strength SPECIAL TESTS: *Hawkins *Neer Three stages: *Stage 1- edema and hemorrhage *Stage 2- cuff fibrosis, thickening, partial cuff tearing *Stage 3- full-thickness tendon tears, bony changes, tendon rupture Tx: goal is to preserve subacromial space *Acute- ICE, NSAIDs, PT *Chronic -Corticosteroid injection -More PT -Surgery

*Rotator cuff impingement (impingement syndrome)*

*Loss of the normal integrity of the suspraspinatus and/or infraspinatus tendons S/Sx: -Pain -Weakness -Stiffness -Popping -Unable to sleep PE: -Decreased ROM -Pain with abduction and return from full abduction -Weak in abduction (especially first 10 degrees) -Pain with resisted external rotation -TTP GT, RTC tendons -positive empty can *Pathogenesis: -Traumatic injury -Ageing factors -Vascular factors -Mechanical factors *Imaging: -X-ray may show mild displacement of humeral head superiorly -MRI may show direction and thickness of tear Tx: -Conservative first (?): depends on thickness of tear, age of pt, occupation... *PT! *ICE *NSAIDs -If no relief with conservative tx, resort to SURGERY

*Rotator cuff tear*

Inflammation of the subacromial bursa -Typically secondary to shoulder impingement -Presentation *S/Sx same as impingement Tx: -PT for RTC strengthening -ICE -NSAIDs

*Subacromial bursitis*

*Refers to sx's that are produced by obstruction of the nerve bundle serving the arm as it passes through from the thoracocervical region to the axilla. S/Sx: *Neurogenic: -Supraclavicular and anterior chest wall burning pain -Segmental pain and paresthesias in ulnar distribution -Weakness of intrinsic muscles of the hand *Vascular -Color change, ischemic symptoms -Swelling -Venous dilation -Diffuse arm, forearm, hand swelling PE: -Supraclavicular tenderness -+ Adson test -+Roos test -+Tinel test- nerve -+Allen test- vascular *MCC is sagging musclature related to aging, obesity, or heavy breasts. *Three types/etiologies -Neurogenic -Vascular -Both Tx: -Pt taught joint protection -Posture correction -Exercises to strengthen surrounding muscles -Support bra -Surgery

*Thoracic outlet syndrome*