Shoulder ppt
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![Page 1: Shoulder ppt](https://reader033.fdocuments.in/reader033/viewer/2022052304/55a205681a28abdf648b4674/html5/thumbnails/1.jpg)
CME on Approach to Shoulder Pain Assessment&Evaluation
Presenter:
Dr. Fahad IslamHonorary Medical Officer, CMCH
Physical Medicine &Rehabilitation Department
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SHOULDER JOINT
Patient Evaluation
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SHOULDER JOINT
*Multiaxial Ball& Socket type of synovial joint
*Most flexible joint in the entire human body due to limited interface
*Formed by the articulation between the glenoid fossa of scapula& Head of Humerus
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ANATOMY..
• Shoulder Girdle: humerus, clavicle, scapula & sternum
• Physiologic area: subacromial space• Muscles• Non-contractile structures (ligament,
capsule, bursa, labrum, nerves & blood vessels)
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Bursa around Shoulder
1.Subdeltoid Bursa
2.Subcoracoid Bursa
3.Coracobrachial Bursa
4.Subacromial Bursa
5.Subscapular Bursa
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Ligaments
1.Superior, middle and inferior glenohumeral Ligaments
2.Coracohumeral Ligaments
3.Transeverse humeral ligaments
4.Coraco-acromial Ligaments
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Nerve Supply
1.Suprascapular N
2.Axillary N
3.Lateral Pectoral N
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Blood Supply
The glenohumeral joint is supplied with blood by branches of the-
1.Anterior and Posterior circumflex humeral,
2.Suprascapular arteries and
3.The scapular circumflex arteries.
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PURPOSE OF SHOULDER ASSESSMENT
• Verify the nature and extent of impairments (e.g. pain, movement restriction, impaired proprioception etc.)
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• Ascertain the degree of the resulting disability (e.g. difficulty throwing, inability to perform freestyle stroke etc.)
• Gather significant information about the patient (e.g. level of motivation, expectations, occupation, sport activities etc.)
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SUBJECTIVE EXAMINATION
• Patient’s profile– Age– Occupation– Hand dominance– Recreational pursuits– Work requirements– ADL
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• Comfortable/ Preferred limb position
• Mechanism of Injury– Overhead exertion involving
repetitive motion – Fall or blow to tip of shoulder or
land on elbow– Shoulder feels unstable or “coming
out”
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• Body Chart– Symptomatic representation of pt’s
complaints– Most important element of subj
examination• Movements that cause pain or
problems? – Lateral rotation- ant. Dislocation– Dead Arm Syndrome – ant. instability– Night & Resting pain- rotator cuff tear– Activity related pain- tendinitis– Pain greater than 90 degrees of ABD-
AC joint
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• Extent & behavior of patient’s pain (e.g. deep, boring, toothache-like pain – TOS)
• Activities that causes or aggravates pain (e.g. overhead elevation – impingement)
• Pain relieving positions (e.g. overhead – nerve root pain)
• Functional capabilities of the patient
• Onset and duration of sx? (e.g. frozen shoulder – 3 stages)
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• Any indication of muscle spasm, deformity, wasting, bruising, paresthesia or numbness?
• Any feeling of heaviness and weakness of the limb after activity? (e.g. TOS – coolness & pallor)
• Any indication of nerve injury? (paresthesia, numbness, weakness)
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Chief Complaints
1.Pain-True/referred
*AC joint/Referred pain=Top of the Shoulder *Glenohumeral Joint/rotatory cuff= Front& outer aspect of joint as far as the middle of the arm. *Rotatory cuff impingment=pain in Window cleaning position *Shoulder instability=Sudden pain in over headed position
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2.Weakness
*True Loss of power=Neurological disorder *Sudden& Surprising inability to abduct=Rotatory cuff Tear
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3.Instability-Feeling of shoulder jumps out of its socket when raising arm, Click/Jerk when arm is held over headed. 4.Stiffness-May be Severe/progressive---Frozen Shoulder 5.Swelling-may be Joint/Muscle/Bone
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6.Deformity-May be either Muscle wasting,AC jt prominence,Winging of scapula,or an abnormal position of the arm 7.Loss of Function-Expressed as difficulty with dressing &grooming or inability to lift objects or work with the arm above shoulder height.
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Examined from front, side, behind & above, both upper limb, Neck ,upper chest& outline of Scapula must be visible
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OBSERVATION• Observe shoulder,
head, cervical spine, thorax (anterior & posterior
aspects) & entire UE
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ANTERIOR VIEW• Step Deformity
– Distal end of clavicle lying superior over the Acromion Process (AC dislocation)
• Sulcus Sign– Sulcus below Acromion (GH
subluxation)• Flattening of deltoid muscle:
ant dislocation of GH jt or deltoid paralysis
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STEP DEFORMITY
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SULCUS SIGN
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POSTERIOR VIEW• Examine for bony contours &
alignment• Atrophy: Upper trapz,
supra/infraspinatus• Winging of the scapula: medial
border moves away from posterior chest wall
• ROTARY WINGING- inf angle is rotated farther from the spine
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• DYNAMIC WINGING- with mov’t caused by lesion in long thoracic nerve & spinal accessory nerve
• STATIC WINGING- at rest due to structural deformity
• SCAPULAR TILT- superior/ inferior border tilt away from the chest
• SPRENGEL’s DEFORMITY- congenitally high or undescended scapula
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WINGING of the SCAPULALong ThoracicNerve Lesion
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SPRENGEL’S DEFORMITY
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FEEL
1.Skin-Temparature 2.Bony points &Soft tissues *6 Points= SC jt,trace clavicle, AC jt, Ant. Edge of Acromion& Around acromion, Ant.& Post.margin of glenoid, Bicipital groove *Supraspinatus Tendon =Palpated just under the Ant. edge of Acromion(Crepitus+=Tendinitis/Tear) Below this Tendon bony prominences bounding the Bicipital groove easily felt if the gently Rotated.
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EXAMINATION
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Range of Motion 3 CLASSIC SHOULDER
CASES–JOINT PATHOLOGY–MUSCLE/ TENDON PATHOLOGY
–NERVE COMPRESSION INJURIES
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MOVEMENTS
Observed from Front, then behind, Pt either standing/sitting
1.AROM
a. Abduction(0-170)&Adduction(0-50) b.Flexion(0-165)& Extension(0-60) c.Horizontal Flexion &Adduction=0-140 degree d.Internal rotation in abduction=0-70 degree
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AROM..continue
e. External rotation in abduction=0-100 degree f.External rotation in extension=0-70 degree
g.Internal rotation in extension 0-70 degree h.Shoulder Elevation=37 degree i.Shoulder depression=8 degree
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CONTINUE..
2.PROM-Examiner press Firmly down on the Top of the shoulder with one hand while the other hand moves the Pts arm
3.Power
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COMMON CAUSES OF SHOULDER PAIN
A. Joint patholgy- GH arthritis,AC arthritisB. Rotatory cuff patholgy-Impingement,
Tendinitis, Tear, Frozen shoulderC. Bone pathology-Infection,TumorD. Nerve patholgy-Suprascapular N
entrapmentE. Referred Pain-
C/Spondylosis,Mediastinal &Cardiac Ischemia
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Disorder of Rotatory Cuff (Rotatory Cuff Syndrome)
Comprises at least 4 condition with distinct clinical features& conditions:
1.Supraspinatus impingement syndrome& Tendinitis
2.Rotatory cuff tear
3.Acute calcific Tendinitis
4.Biceps Tendinitis and,or/ Rupture
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Impingement site
pics-1.lnk
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Impingement Syndrome
Pathology:
1.Repetitive compression or rubbing of the tendons under coracoacromial arch specially in Impingement position
2.Osteoarthritic Thickening of AC joint
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Impingement Syndrome- pathology. continue
3.Osteophyte on the ant. Edge of acromion
4.Inflammatory swelling of rotatory cuff or subacromial bursa.eg: Gout,RA
5.Acromial Morphology.
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Pathology..continue
6.Friction in Old age may leads to minute tear of cuff
7.Sudden strain-partial/full thickness tear, associated with Biceps tendon tear.
8.Secondary arthropathy
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Clinical features of Rotatory Cuff Syndrome
3 Pattern are encountered:
1.Subacute tendinitis-Painful arc syndrome
2.Chronic tendinitis
3.Cuff disruption
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Impingement Test
1.The Painful arc-on active abduction (60-120 degree)
2.Neer’s Impingement sign: 80 percent sensitive. also (+)ve in Rotatory cuff tear, AC joint OA, Glenohumeral instability& SLAP lesions.
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1.PAINFUL ARC
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2.NEER IMPINGEMENT TEST
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3.HAWKINS-KENNEDY IMPINGEMENT TEST
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continue..
TEST FOR ISOLATED MUSCLE WEAKNESS
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1.Supraspinatus-EMPTY CAN TEST
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2.INFRASPINATUS TEST- resisted external rotation
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3.DROP ARM TEST-found in Infraspinatus &Post. cuff tear
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4.LIFT-OFF SIGN / TEST subscapularis pathology
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Investigations
1.X-ray examination- early stages found normal, but in
*Ch. tendinitis= erosion, sclerosis& Cyst formation at the site of cuff insertion
*In Ch. Case caudal tilt view show roughening or overgrowth of ant. Edge of acromion& upward displacement of humeral head
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Investigations..
2.MRI-gives valuable information about structures like lesion of glenoid labrum, joint capsule or surrounding muscle, bone.
3.USG-identifying and measuring the size of full thickness or partial thickness tear.
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Treatment of Cuff disorders
Conservative:
1.ADLs modification
2.Physiotherapy=UST
3.AROMs
4.NSAIDs,I/A depot corticosteroids
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CONTINUE
Surgical management:
*When conservative treatment fails after 3 months
*Symptoms persist or worse after adequate treatment
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CONTINUE
1.Decompress rotatory cuff by excising coracoacromial ligament,undercutting the ant. Part of acromion
2.Open/Arthroscopic acromioplasty
3.Open/Arthroscopic repair of the rotatory cuff
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Calcification of the Rotatory cuff
Acute calcific tendinitis:*deposition of CPPD crystal in critical zone, also occurs in
ankle, knee, hip, elbow
*Cause is unknown, supposed that ischemia leads to fibrocartilaginous metaplasia& crystal deposition by chondrocytes.
*Florid vascular reaction produces tension& swelling of the tendons causes pain
*Resorbtion of calcific materials is rapid with in few weeks.
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C/F of Acute calcific tendinitis
1.30-50 yrs age
2.Aching pain develops with in hours after overuse, raising to an agonizing
3.After few days pain subside
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X-ray findings
1.Calcification just above greater tuberosity
2.Well demarcated deposit becomes more woolly and then dissappears.
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Treatment of Acute calcific tendinitis
Conservative Mx:
1.NSAIDs
2.Subacromial I/A steroids
3.Physiotherpay
4.Extra corporeal shock wave therapy
5.Needle aspiration& Irrigation
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Management continue
Surgical Mx: after 6months of conservative treatment
*Arthroscopic incision from bursal side with fibre orientation of the tendon,then curette to milk out the tooth paste deposit.Sub-acromial decompression may also done.
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Lesions of the Biceps Tendon
1.Tendinitis
2.Rupture:Pop-Eye Bulge
3.Hypertrophy & Intra-articular entrapment (The Hour glass Biceps)
4.Instability*Subluxation-Partial&/transient loss of contact between the
tendons& its groove
*Dislocation-complete& permanent loss of contact between the tendons& its groove
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TEST FOR BICEPS TENDON
1.Speed’s Test
2.Yergason’s Test
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1.Speed’S Test
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2.Yergason’s Test
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SLAP Lesions
Compressive loading of the shoulder in the flexed abducted position like fall on the out-stretched hand.4 main types:
1.Non-traumatic(degenerative) sup. labral tear
2.Avulsion of the sup.part of labrum(commonest)
3.A Bucket handle tear of Sup.labrum
4.Bucket handle tear with its extension into long head of biceps
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Special Test:O’Brien Test
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SHOULDER INSTABILITY
1.Type I: Traumatic structural(Ant.) Instability
2.Type II: Atraumatic /minimally traumatic structural instability, multidirectional instability eg:repetitive microtrauma/overall laxity like during swimmers, athelets, throwers
3.Type III: Atraumatic non-structural instability(muscular dyskinesia)
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Shoulder Instabilities
• Instability Anterior– Crank (apprehension) test– Anterior Drawer Test
• Instability Posterior– Posterior Drawer Test– Posterior Apprehension Test
• Instability Inferior– Sulcus Sign
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APPREHENSION TEST FOR ANTERIOR SHOULDER
DISLOCATION
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POSTERIOR APPREHENSION TEST
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DRAWER TEST
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SULCUS SIGN
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LOAD AND SHIFT TEST
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FROZEN SHOULDER
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Frozen Shoulder
* Progessive pain and stiffness of the shoulder joint which spontaneously resolve after 18 months.
*Restricted both active &passive ROMs in all planes.
*commonly associated with DM, Hyperlipidaemia, Hyperthyroidism, Dupuytren’s disease, IHD, Inflammatory arthritis & C/Spondylosis
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Continue..
Passes in 3 stages:
1.1st stage/Freezing phase: 3-6months
2. 2nd stage/Frozen phase/Progessive stiffness: 3-18 months
3.Final stage/Resolution/Thawing phase: 3-6 months
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Test for Frozen shoulder
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Treatment
Diagnosis is clinical. Rx combining:
1.ADLs modification
2.NSAIDs
3.I/A Steroid,or 50-200 sterile saline under pressure
4.Codman pendulum ex is very effective
5.Physical agent: UST
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Thank you ..