Shoulder Complex - Exam & Diagnoses

Which outcome measures can be used?

1. Shoulder Pain and Disability Index (SPADI)

2. Disabilities of the Arm Shoulder and Hand (DASH)

What is the purpose of the objective exam?

1. To increase or decrease the probability of your hypotheses

2. Reproduce the symptoms the patient is reporting

3. Find impairments that are most COMPARALE to the chief complain (comparable sign)

How do you select tests and measures?

Based on primary hypothesis & SINSS

________ and ______ will determine the volume and vigor of your objective exam

Severity, irritability

How do you establish a BASELINE of symptoms?

"How are you feeling right now?"

- location

- quality

- severity

- comparability (is that like the symptoms you've described?)

When should you ask for a baseline?

- Every positional change

- Before any movement

- After several tests (latency)

What makes up a functional screen for the shoulder?

1. "Can you show me?"

2. Reaching overhead

3. Reaching behind

What is "clearing a joint"?

Determining if another joint is contributing to the patient's CURRENT symptoms

In the presence of gradual onset and vague symptom location, ASSUME __________ involvement until proven otherwise

Cervical spine

Progress through standard movements of the shoulder.

Flexion --> extension --> abduction --> IR with the arm at side --> ER with the arm at side --> horiz. abduction --> horiz. adduction

Explain normal scapular kinematics during elevation.

Upward rotation + posterior tilting + slight external rotation

Why is asymmetrical scapular movement more commonly seen during the descending phase?

Increase in strength required in the eccentric phase of the movement

What are combined movements of the shoulder?

Hand behind head & hand behind back

How do you position the patient for PROM?

Supine (promotes relaxation)

Normal end feel: shoulder flexion/extension

Tissue stretch (firm)

Normal end feel: shoulder abduction

Bone-to-bone (hard) or tissue stretch (firm)

Normal end feel: shoulder external/internal rotation

Tissue stretch (firm)

Normal end feel: shoulder adduction

Soft tissue approx.

Normal end feel: horizontal adduction/abduction

Tissue stretch (firm)

What is the purpose of a diagnosis?

- Improves communication w/ the client

- Provides clarity for the client

- Guides treatment selection

- Improves understanding of a client's prognosis

What are the 4 patient presentation categories?

1. Red flag

2. Persisting pain

3. Region-specific disorder

4. Non-specific region disorder

What is the purpose of classification systems?

Assist clinicians in achieving a working hypothesis, guide the selection of diagnostic tests and interventions, and inform prognosis --> ID treatment priorities

Why are MSK disorders worsening in chronicity and disability?

The biomedical model has led to:

- "Fix it" narrative

- Too much medicine

- Medicalizing normalcy

- Low-value care

*some clients do not have a singular MSK or biological cause!! look at the WHOLE person!!*

___________ is a patient presentation that involves changes in the CNS due to persisting peripheral nociceptive input

Persisting pain

_______________ function very well to ID region-specific pathology

Clinical tests and measures

___________ is the propensity to experience and report mechanical symptoms that have no biological explanation

Non-specific region disorder

What type of patient presentation is the most common in outpatient PT?

Non-specific region disorder

Example: shoulder pain & mobility deficits classification

Frozen shoulder

Example: shoulder stability and movement coordination impairments

Dislocation of the shoulder

Example: shoulder pain and muscle power deficits

Rotator cuff-related pain syndrome

Describe the classification of frozen shoulder

Shoulder pain and mobility deficits...disorder that affects the capsular tissue of the shoulder & is characterized by shoulder pain --> sig. loss of shoulder movement in MULTIPLE planes

______ (primary/secondary FS) arises spontaneously w/o an obvious preceding event & no local or systemic disorders

Primary

_________ (primary/secondary FS) occurs in the presence of an underlying comorbidity or following trauma or surgery

Secondary

List the 3 subcategories of secondary FS

1. Systemic (diabetes, thyroid)

2. Extrinsic (ex: CVA)

3. Intrinsic (ex: rotator cuff tear)

What is the pathophysiology of frozen shoulder?

Complex process that involves some type of trigger inducing an inflammatory response w/ excessive scarring

Describe the stages of frozen shoulder

1. Freezing

2. Frozen

3. Thawing

Stage # involves inflammatory changes w/ synovial hyperplasia, hypervascularity, and neurogenesis

Primary symptom: pain

Stage 1 (freezing)

Stage # involves ongoing synovitis and progressive capsular contracture; fibroblasts --> myofibroblasts

Symptoms: ongoing pain w/ progressive limitation in motion

Stage 2 (frozen)

Stage # involves hardening of axillary folds, thickening of the synovial capsule, contracture of the GH capsule, new nerve growth

Stage 3 (thawing)

Which type of collagen is normal at the GHJ? Which type of collagen is abundant in FS?

Type I...Type III

At what stage of FS does pain reach its peak?

Stage II

During which stage of FS does pain decrease and ROM improves?

Stage III

What is the typical timelines for FS?

12-48 months

ID s/s consistent w/ frozen shoulder

- Age: 40-65

- Female > male

- Diabetes and thyroid disorder

True or false: x-rays are unremarkable for FS

TRUE!! X-rays are poor tools for inflammatory conditions

What is the hallmark sign of FS?

Early loss of ER ROM w/ arm at side -- with pain at end ROM

What is the challenge w/ the hallmark sign of FS being early loss of ER ROM w/ arm at side?

Rotator cuff-related pain syndrome also presents w/ this sign

What are common physical exam findings for FS?

- >25% loss of AROM in 1+ directions due to PAIN

- PROM into the end ranges of motions reproduce symptoms

- Accessory motion limited in ALL direction

- Sig. functional deficits

- Isometric muscle testings should elicit little to no weakness or pain

Which tissue is involved in glenohumeral OA?

- Hyaline cartilage

- Subchondral and periarticular bone

- Periarticular soft tissues (muscles, tendons, bursa, synovium, joint capsule, and ligaments)

What is the consequence of a fissure?

Decreases load-bearing capacity of the joint

True or false: glenohumeral OA is diagnosable w/ radiographic evidence

TRUE -- recall: frozen shoulder, however, is NOT!!

Describe the pathophysiology of glenohumeral OA.

Focal or global cartilage loss + subchondral bony sclerosis

What occurs as glenohumeral OA progresses?

1. Humeral head flattens

2. Osteophytes develop (response to repeated stress that limits motion)

3. Erosion of glenoid

What are the risk factors of glenohumeral OA in younger patients?

Prior trauma, dislocation, or previous surgery for shoulder instability

What are the types of factors leading to glenohumeral OA?

Specific & non-specific factors

Systemic & local factors

True or false: glenohumeral OA is just "wear and tear"

FALSE--there is an interplay of factors that leads to a cascade of low-grade inflammation --> joint breakdown

Age, obesity, and genetics are ________, ________ risk factors

Non-specific, systemic

Age --> chondrocyte density and responsiveness to growth factors diminish

Obesity --> excessive adipose impacts endocrine function, which promotes inflammation

Genetics --> predisposal to inflammation, obesity, and malalignment of joints

Activity level & occupation are ______, ________ risk factors

Non-specific, local

Activity level --> increased joint surface wear initiates a cascade of biochemical changes

Occupation --> heavy work w/ repetitive movements of the upper extremity

Glenohumeral instability and surgery, fractures, & rotator cuff tears are _______, ________ risk factors

Specific, local

Instability and surgery: inflammatory environment and altered biomechanics

Fractures: macroscopic damage to articular cartilage --> exaggerated inflammation --> rapid joint destruction (posttraumatic OA)

Rotator cuff tears: superior migration of the humeral head erodes the superior glenoid and coracoacromial arch

Inflammatory arthritis, avascular osteonecrosis, & endocrine diseases are __________, _______ risk factors

Specific, systemic

Inflammatory arthritis: RA, psoriatic arthritis, systemic lupus

Avascular osteonecrosis: bony collapse and loss of joint congruity

Endocrine: diabetes, thyroidism

Describe the clinical presentation of glenohumeral OA.

- Age: >60

- Progressive, activity-related pain deep in the joint located posteriorly

- Night pain

- Stiffness

- Crepitis

- Joint effusion

Early in the disease process, radiographic evidence includes:

- Joint-space narrowing

- Osteophytes

- Subchondral sclerosis

- Cysts

Why is our language important when describing the process of OA to our clients?

Biomedical explanations may negatively influence activity...DO NOT SAY "WEAR AND TEAR"!! SAY "NORMAL AGE-RELATED CHANGE"!!

___________ is a progressive and DEGENERATIVE joint disease involving a low-grade chronic inflammatory process that causes articular cartilage cell injury

Glenohumeral osteoarthritis

What are indications for a TSA?

- Complex humeral head fractures

- Severe pain

- Inability to perform ADLs

- Failed conservative management >8-12 weeks

What is the success of a TSA dependent on?

Proper functioning of surrounding soft tissue (i.e., rotator cuff)

How is the TSA approach performed?

Deltopectoral approach (detach the subscapularis and capsule from the anterior Humerus; dislocate shoulder anteriorly)

Complications w/ a TSA usually involve the _______ nerve

Axillary

What are the components of the prosthesis?

Titanium alloy (humeral head & stem) + polyethylene (glenoid)

How do you make decisions for TSA rehab?

Tissue healing, patient severity, and irritability

Protection of __________ tendon repair is critical

Subscapularis

- wear a sling 4-6 weeks post-op

- limit passive ER for 3-6 weeks

- limit active IR for 3-6 weeks

What is an alternative approach to a TSA?

Reverse TSA

Who is a candidate for a RTSA?

- Severe glenohumeral arthritis w/o a functioning rotator cuff

- Complex fractures

- Revision of a previously failed conventional TSA in which the rotator cuff tendons are deficient/absent

The RTSA biomechanics involves the ___________ of the orientation of the shoulder joint

Reversal (glenoid fossa --> glenoid base plate and ball, humeral head --> shaft and CONCAVE cup)

What does a RTSA do to the center of rotation of the shoulder?

Moves it medially and inferiorly

What does a RTSA do to the deltoid?

Increases its moment arm and deltoid tension (to compensate for the deficient rotator cuff)

What are the RTSA surgical outcomes?

- Increases in active shoulder elevation

- Movement in transverse plane has not been reprted to improve

Expert opinion states the most important postop concept is enhancement of _________ function

Deltoid

Which GHL provides stability when the arm is at your side?

Superior

Which GHL provides stability when the arm is abducted 45-90 degrees?

Middle

Which GHL provides stability when the arm is abducted 90 degrees (or higher)?

Inferior

What are the 4 static stabilizers of the humerus?

1. Articular conformity of glenoid & humeral head

2. Negative intra-articular pressure ("suction effect")

3. Glenoid labrum (deepens socket)

4. GHL complex

What are the 4 dynamic stabilizers of the humerus?

1. Rotator cuff (SITS)

2. Long head of the biceps

3. Scapular stabilizers

4. Deltoid

___________ is ASYMPTOMATIC glenohumeral hypermobility during AROM & PROM w/ the ability to maintain centering of the humeral head in the glenoid fossa

Laxity

_________ is the loss of the ability to center the humeral head in the glenoid fossa during shoulder activity associated w/ SYMPTOMS

Instability

What are some symptoms of instability?

Pain, discomfort, paresthesia, apprehension, fatigue

__________ is translation BEYOND normal physiological limits, but the humeral head is maintained in the glenoid fossa

Subluxation

0-25% translation = ________ (normal laxity/subluxation)

Normal laxity

25-50% translation = grade ______ subluxation

Grade I

>50% (feeling of the humeral head over riding the rim, but spontaneously reduces) = grade ______ subluxation

Grade II

50% (feeling of the humeral head over riding the rim) = grade _______ subluxation

Grade III

Complete disassociation of the humeral head of the glenoid fossa is known as ________, and it typically occurs in which direction?

Dislocation, anterior

How can you classify instability?

- Etiology (traumatic vs. atraumatic)

- Frequency

- Direction of instability

- Severity

What does AMBRI stand for?

Atraumatic

Multidirectional

Bilateral

Rehab-effective

Inferior capsular shift (if rehab is NOT effective)

_________ is an excessive joint translation in 2+ directions WITH activity-related symptoms due to significant ligamentous and capsular laxity

AMBRI

Which capsule is affected the most in AMBRI?

Inferior

True or false: even though AMBRI is multidirectional, clients usually have a PRIMARY direction of instability

True!!

________ (inferior/anterior/posterior) instability is reproduced w/ overhead activities or carrying objects

Inferior (arm is is abducted > 90)

_______ (inferior/anterior/posterior) instability is reproduced w/ overhead movements and ER such as throwing a ball or swimming

Anterior

_______ (inferior/anterior/posterior) instability is reproduced w/ flexion and IR movements such as pushing open a heavy door or performing push-ups

Posterior