SHOULDER CASE

What percent of people with RCT between ages of 50-65 are asymptomatic?

close to 100%

What are things to consider regarding imaging and RCT?

• most people with RCT are asymptomatic

• need to evaluate muscle strength via selective tissue tension testing and see if imaging corresponds with screening results

• if selective tissue testing is normal = patient is fine

What are subjective outcome measures for the shoulder joint? What does a score on each mean?

DASH: higher score = greater level of disability and symptom severity

SPADI: scoring for pain + disability; higher score = greater level of disability and pain severity

What are the main drivers in examination of a RCT?

• selective tissue testing

  • strong + painful = tendinopathy

  • weak + painful = partial tear

  • weak + no pain = full tear

• ROM…should be a difference!

  • AROM limited

  • PROM full range

• palpation

  • will be tender over area

  • supraspinatus tendon: referrs pain to deltoid tuberosity

• special tests

  • Hawkins-Kennedy: rule out

  • Painful arc: to rule in

What is the most important intervention for RCT?

• loading the tendon

• eccentric exercises

What type of tissue is likely affected/impaired if a patient has limitations in both AROM and PROM?

• non-contractile

  • joint capsule

  • ligament

  • bone

  • nerve

What type of tissue is likely affected/impaired if a patient has limitations in AROM but none in PROM?

• contractile

  • muscle

  • tendon

Patients with COPD who complain of shoulder arm pain might have what pathology?

• thoracic outlet syndrome

• scalene triangle hypertrophy due to shallow breathing

  • uses more scalenes than diaphragm

How can you differentiate thoracic outlet syndrome from cervical radiculopathy?

shoulder AB test

• cervical radiculopathy: will relieve pain

• thoracic outlet: will make pain worse

How can you differentiate thoracic outlet syndrome from carpal tunnel syndrome or cubital tunnel?

patient presentation: there will be a different pattern of symptoms

• thoracic outlet syndrome:

  • can be arterial, venous, or neurogenic

  • arterial: hand or arm ischemia (reduced distal pulses), chronic arm, neck, shoulder pain

  • venous: edema, symptoms worse with OH motion

  • neurogenic: paresthesia, atrophy, pain in shoulder or arm

• carpal tunnel syndrome:

  • symptoms distal to wrist vs. whole arm

  • tinel sign: tap over area causes pins and needles sensation

• cubital tunnel

  • compression of ulnar nerve

  • leads to numbness/tingling of 4th and 5th digits

What are the three main types of thoracic outlet syndrome? Explain the symptoms involved with each and what other conditions to screen for with each

• arterial

  • hand/arm ischemia

  • chronic arm, neck, shoulder pain,

  • RULE OUT: peripheral artery disease (more likely symp: reduced distal pulses to lower extremities)

• venous

  • edema

  • symptoms worse with OH motion

• neurogenic

  • paresthesisa in arm/hand

  • pain that is “radiating” feels like “pins and needles”

  • atrophy, pain in shoulder or arm

  • RULE OUT: carpal tunnel, cubital tunnel

If there a patient experiences pain early in the motion of AB which joint is likely affected: SC or AC?

• SC joint

• this is because SC joint motion occurs at the beginning of arm elevation

If a patient experiences pain late/endrange in the motion of AB which joint is likely affected: SC or AC?

• AC joint

• this is because AC joint motion occurs towards of arm elevation

What is the difference between a Bankart lesion and a Hill Sachs lesion? What conditions are they typically found with?

Bankart lesion:

• tear of the anterior inferior glenoid labrum which leads to anterior instability

• typically caused by traumatic shoulder dislocation

Hill Sachs lesion

• posterior-superior osteochondral impaction fracture of humeral head

• typically caused by anterior dislocation

• reverese hill sachs seen with posterior dislocation

Why are SLAP lesions common with shoulder instability?

• they result in loss of suction cup effect of labrum

What are the different slap tears?

Type I:

• degenerative

• fraying of free edge of labrum:

• insertion to superior glenoid remains intact

Type II:

• acute

• labrum and long head of biceps tendon torn off from cavity

Type III:

• “bucket-handle” pattern

• insertion of long head of biceps tendon unaffected

Type IV:

• type III pattern except it does affect the long head of the biceps tendon

Explain the pathophysiology of tendinosis, how is it different from tendonitis?

Tendinosis

• degeneration of tendon’s collagen in response to chronic overuse

• increased ground substance and pathologic vascularization

• increase in immature type III collagen fibers

• primary treatment goals:

  • break cycle of injury: reduce ground substance, tendon thickening

  • optimize collagen production and maturation (type III to type I! with loading!)

tendinitis

• inflammation of a tendon that results from micro tears

• occurs when acutely overloaded with force that is too heavy/sudden

• primary treatment goal will be to reduce pain and inflammation

Should a patient with tendinosis be taking Ibuprofen?

• no

• Ibuprofen is associated with inhibited collagen repair

What are the NORMAL stages of a tendon injury?

• inflammatory/hematoma formation

• proliferation

• remodeling

  • type III collagen is laid down: disorganized, doesn’t have tensile strength like type I

  • need proper loading to convert type III collagen into type I

What questions would you ask a person if you suspect a rotator cuff tear?

• onset of pain (did trauma precede?)

• location of pain

  • pain over deltoid tuberosity could be referred for supraspinatus tear

• motions/functional movements that make the pain worse/better

  • OH, AB, ER, IR

• activities: work, sports, recreation

  • looking to see if repetitive motion, overuse, repetitive stress might be an issue

• what have they done for it so far?

  • has it helped? made things worse?

  • what medications are they taking?

What questions would you ask a person (and why) if you suspect tendinopathy?

• onset of pain

• location of pain

• types of activities: work-related, sports, recreation

  • looking to see if repetitive stress

What questions would you ask a person (and why) if you suspect adhesive capsulitis?

• onset of pain: expecting them to say insidious

• functional movements that make the pain worse or are limited due to pain or stiffness

  • expecting difficulties with OH/flexion: reaching in cabinet

  • ER: washing hair

  • IR: tucking in shirt, putting on bra

• type of pain: dull, aching

• any imaging (to rule out other DD like OA)

What questions would you ask a person (and why) if you suspect labrum tear or instability?

• onset of injury: atraumatic: AMBRI; traumatic: TUBS

  • Atraumatic, multidirectional, bilateral shoulder findings, rehabilitation, inferior capsule shift

  • Traumatic onset, unidirectional anterior, bankart lesion, surgery  

    • if trauma/dislocation

      • anterior: arm was likely AB + ER: most common type

      • posterior: arm was likely AD + IR

• feelings of instability/apprehension with movement

• location of pain, type of pain

• activities: work-related, sports, recreational

• imaging

  • Bankart lesion

  • SLAP lesion

  • hill-sachs lesion

How does ROM and strength differ with different diagnoses (specifically RCT and frozen shoulder)

RCT

• AROM limited but PROM normal

• AROM limited due to pain or weakness of a partially or fully torn tendon

• PROM not limited/painful bc no contraction occurring so nothing is pulling on tendon

frozen shoulder

• AROM: limited by pain and stiffness

• PROM: also limited by stiffness of joint capsule (likely also pain)

• capsular pattern: ER, FLX, IR

What type of cancer might you suspect a patient to have if the pain in their typically painful shoulder goes away when they lay on it?

• pancoast

How useful are special tests with shoulder “impingement”

• not very useful

• can’t really rule it in because the position you put the patient in could cause pain if they had a number of pathologies

• nothing is really being impinged, the tests really are just aggravating something

What are the normal ROM values for the shoulder?

• flexion: 180

• extension: 60

• AB: 180

• AD: 20

• ER: 90 (70 is functional though)

• IR: 70

Explain the pathophysiology of adhesive capsulitis (and stages)

• insidious development of progressive pain and stiffness of the joint capsule of the shoulder

• usually three stages: freezing, frozen, thawing

• freezing stage: 3-9 months

  • severe pain, motion mainly limited due to pain

• frozen stage: 10-14 months

  • less pain, more joint stiffness; ROM limited due to stiffness more than pain

• thawing: 14-24 months

  • gradual return of shoulder ROM and reduction of pain

How can PT help frozen shoulder in the long-term?

• PT with gentle ROM and joint mobilizations early on can result in less mobility that is lost over the progression of frozen shoulder

• ROM is going to be lost but, will have less to regain once stages are over

What are some medications a patient might be taking based on the following presentations: diabetes, hypertension, bipolar disorder, anxiety/OCD, schizophrenia, pain

diabetes

• metformin

hypertension

• beta blockers: metropolol, atenolol, propanolol

bipolar disorder

• lithium

anxiety/OCD

• sertraline/zoloft (SSRIs)

schizophrenia

• antipsychotics

pain

• OTC: acetaminophen (Tylenol), NSAIDs (ibuprofen)

• prescription: oxycodone

What are SSRIs used for and what are common examples?

• selective serotonin reuptake inhibitors

• used to treat anxiety/OCD

• sertraline (zoloft), prozac, lexapro

What is the risk of taking too many corticosteroids?

• corticosteroids affect bone mineral density which can increase risk of fracture

  • increase osteoclastic activity but inhibit osteoblastic/osteocytes

Why is diabetes mellitus a risk factor for frozen shoulder?

• diabetes causes glycation of collagen

  • excess sugar in bloodstream attaches to collagen making it thick and sticky, affecting ROM

• increased inflammation

• person more at risk for having frozen shoulder in both shoulders

How do behavioral pathologies and medications impact interventions?

• patient might not be compliant with interventions or HEP

  • especially if patient has compliance issues with taking medications

• specifically bipolar

  • during manic episodes: might not think they need therapy because they feel good

• patient education on importance of doing PT exercises both on good and bad days very important

What is the timeline for frozen shoulder?

freezing: 3-9 months

frozen: 10-14 months

thawing: 14-24 months

What are important things to ask in subjective?

• onset

• pain

  • location, type

• functional movements: difficult, painful, both?

• PMHx and red flags screen (obvi)

• course of care

  • who have they seen for it

  • what have they done: medication, exercise

  • has anything made it better, worse?

  • have they had any imaging?

    • be prepared to explain the usefulness of imaging

• yellow flags

  • occupation

  • family/living/support

  • ACTIVITIES: what does day to day look like? sports? recreation? work?

  • social factors

  • fear avoidance, anxiety, depression

  • PHQ-9

• goals

What position should all selective tissue tension testing be done in?

open pack: 30* flx, 30* AB

What is the FIRST intervention you should do with every patient???

PATIENT EDUCATION!!!

What is the issue with bipolar disorder and medication/treatment compliance?

• during manic episodes person might not feel they need to take medication/follow treatment

Alcohol affects which vitamin?

vitamin B

What should you ask patients regarding their prescriptions?

• ask if they are taking as dosed/directed

• trying to see if substance abuse is an issue

What doesn’t help with a person with dementia?

corrections

What red flag symptom might a patient present with if they have a partial rotator cuff tear?

pain at night

• screen for cancer

What are the main drivers in a shoulder examination?

• selective tissue testing

• ROM

  • is AROM limited? PROM limited?

  • difference = contractile tissue issue

  • no difference = noncontractile tissue issue

• palpation and joint play assessment

A patient with frozen shoulder is skeptical about PT treatment. How can you explain to them that it will benefit them in the long run?

• less ROM will be lost which means they won’t have to work to regain as much

How does the rotator cuff act on the GH joint during shoulder elevation? What does it do?

• rotator cuff pulls humerus in and stabilizes it against the glenoid fossa

• labrum also helps keep humerus centered

• muscles need to approximate head on fossa during elevation

Explain scapulohumeral rhythm

• initial motion: more GH motion

• between 60-120*: more scapular motion

• end range: more GH motion

• scapula and clavicle motion occur together

  • so if a person has clavicle issues…they likely will have scapula issues + issues with AB/overhead motion

Why would a patient with rotator cuff issue present with more pain during 60-120* AB?

• there is more muscle activity in this range, so the rotator cuff is working harder

  • rotator cuff working hard to keep humerus stabilized

  • as deltoid activity increases, rotator cuff activity increases

What is the Magee cluster classification for rotator cuff tear?

Hx: age 30-50, weakness after eccentric load

Observation: normal bone + soft tissue outlines; protective shoulder hike might be present

AROM: weakness with AB, ER/IR or both

PROM: pain if impingement occurs (end feel empty if pt doesn’t let you get there)

Resisted isometric movement: pain + weakness with AB and ER

special tests: + drop arm; + empty can

sensory/reflexes: normal

palpation: tender over rotator cuff

imaging x-ray: upward displacement of humeral head

• rotator cuff not doing its job to keep humerus on fossa

What is the Magee cluster classification for frozen shoulder?

Hx: over 45yrs, insidious onset, functional limitation of AB, ER, IR

Observation: normal bone + soft tissue outlines

AROM: restricted, shoulder hiking (shrug test +)

PROM: limited in ER, AB, IR

resisted isometrics: normal with arm in loose pack position

palpation: aching but not painful

imaging: used to rule out other pathologies like OA

What is the Magee cluster classification for atraumatic instability/labrum tear?

Hx: 10-35 yrs, pain and instability with activity, no history of trauma

Observation: normal bone and soft tissue outlines

AROM: full or excessive ROM

PROM: normal or excessive ROM

resisted isometric movement: normal

special tests: + apprehension test, + relocation test

palpation: anterior or posterior pain

imaging: nothing/negative

What is the typical demographic for shoulder instability? What factors can you use to rule in/out?

• younger males

• OH athletes/workers

• hyper mobility

rule IN:

• age under 40yrs

• history of dislocations/subluxations

• apprehension: ask pt: does it feel unstable/are you concerned about it feeling stable?

• generalized laxity

rule OUT:

• no Hx of dislocation

• no apprehension/feeling of instability

What are the CPG for rotator cuff pathology regarding assessment?

A:

• AROM and PROM of shoulder with goni

• isometric muscle strength of shoulder muscles with handheld dynamometer

• patient reported outcome measures: DASH/SPADI

B:

• identifying personal, clinical, psychosocial or work-related factors that may influence prognosis

• special tests: hawkins kennedy to rule out, painful arc to rule in

F:

• prioritizing diagnostic ultrasound imaging if recommending imaging due to low cost

• should also inform patients about limitations of imaging

As stated by the CPG for RCT pathology, what are all the things that should be in the subjective portion of the assessment?

1. reason for consultation

2. age, gender, hand dominance

3. work and related requirements

4. sports and leisure

5. list of medications

6. Comorbidities

7. medical history

8. psychosocial and contextual factors

9. mechanism/history of injury

10. previous investigation/treatments

11. current symptoms: pain, ROM, strength

12. cervical pain and dysfunction; presence of paresthesia

13. functional limitations

14. patient goals

What are the CPG for rotator cuff pathology regarding pharmacological treatment?

B:

• NSAIDs and corticosteroid injections for pain for short-term use

• corticosteroid injections should NOT however be first-line treatment

C:

• acetaminophen for pain for short-term use

summary: okay to take something for pain/reduce inflammation but should only be for short-term use and not first-line treatment

What are the CPG for rotator cuff pathology regarding rehabilitation?

A:

• resistance training for pain reduction as initial treatment

B:

• manual therapy for pain reduction

• should NOT use ultrasound for pain

C:

• patient-center individualized education on condition, pain management, activity modification

• shockwave therapy ONLY if calcification is present

• laser therapy for pain reduction

Explain the research regarding shoulder impingement. What is the new term for this condition?

• research has found that acromionplasty for “impingement” pain is no more beneficial with outcomes compared to non-operative management

• exercise therapy is just as effective as subacromial decompression surgery

  • and also surgery for partial thickness rotator cuff tears

rotator cuff related shoulder pain

What are the CPG for adhesive capsulitis regarding assessment?

What are the CPG for adhesive capsulitis regarding interventions?

A:

• corticosteroid injections

  • can be combined with shoulder mobility and stretching exercises for short-term pain relief

B:

• patient education

  • natural course of disease

  • promote activity modification

  • match intensity of stretching to patient’s current level of irritability

• stretching (intensity determined by irritability)

C:

• modalities for pain relief

• joint mobilizations

What is the CPR for rotator cuff tear?

• pain on shoulder when lying on it at night

• age 45-60

According to the CPG, what are key risk factors to look out for when it comes to adhesive capsulitis

1. diabetes or thyroid disease

2. age 40-65 years

3. female

4. previous adhesive capsulitis in contralateral arm

What are the stages of adhesive capsulitis according to the CPG?

stage 1

• can last up to 3 months

• sharp pain at end range motion

stage 2

• gradual loss of ROM in all directions due to pain

• lasts from 3-9 months

stage 3

• loss of ROM

• lasts 9-15 months

stage 4

• pain that begins to resolve

• can last 15-24 months