-
Upper Quarter Screen: Dermatomes
- C4 = AC Joint
- C5 = Lateral Cubital Fossa
- C6 = Palmar Thumb
- C7 = Palmar Phalanx Middle Finger
- C8 = Palmar Phalanx 5th Digit
- T1 = Medial Forearm
-
Upper Quarter Screen: Myotomes
- C1 = neck flexion
- C3 = neck side flexion
- C4 = shrug
- C5 = abduction
- C6 = elbow flexion
- C7 = elbow extension
- C8 = thumb extension
- T1 = interossei
-
Upper Quarter Screen: Reflexes
- C4 = Levator Scapulae
- C5 = Deltoid
- C6 = Biceps
- C7 = Triceps
- C8 = Extensor Pollicis Longus
- T1 = Thenar Muscles
-
Pancoast's Syndrome
- Tumor invades upper chest wall (upper 2 ribs) & brachial plexus
- c/o scapular and shoulder pain
- Radicular symptoms to C7, C8, and T1
- Sensory changes (ulnar nerve)
- Passive neck side flexion to contralateral side = limited and painful
- Isometric side flexion to ipsilateral side = painful and weak
- Potential absent triceps reflex
-
C7-T1 Metastases
- Lung, breast cancer, and lymphoma
- Pain in paraspinal region radiating to both shoulers
- Tenderness over spinous process
- Nerve root compression - C7, C8, T1
- *Intrinsic hand weakness, triceps, wrist flexors
- *Numbness & paresthesia
-
Diaphragm
- Innervated by phrenic nerves
- C3, C4, C5 (motor and sensory)
- Diaphragm compression can refer pain to shoulder (Supraclavicular nerve C3-C4)
Liver, spleen, gallbladder, compression of diaphragm → sensory fibers (phrenic n.) receive pain signals → signals to spinal cord C3,4 and 5 → brain perceives signals → sends pain sensation to shoulder
-
Organ Referred Pain Locations
- Right Shoulder: Liver & Gallbladder
- Left Shoulder: Spleen
-
Axillary Nerve Injury
- Mechanism: shoulder dislocation
- Atrophy of deltoid
- Sensory changes in C5 dermatome (inferior region of deltoid (sup. lat. cutaneous n.))
- Motor changes in C5 dermatome (deltoid, teres minor)
-
Cervical Spine Special Tests
- Spurling:
- Pt. moves neck into ext, lat flex, and rotation towards side of pain
- Downward compression applied to head
- (+) = radicular pain or paresthesia in dermatomal distribution (secondary to pressure on inflamed nerve root/spinal cord)
- Bakody's Sign:
- Cervical nerve C4-C5
- Raise affected arm over head to rest on top
- (+) nerve compression if relief of radicular symptoms
-
Osteoarthritis: Structural Changes
- Flattening, erosion posterior glenoid
- Posterior subluxation of humeral head
- Deformed humeral head shape
-
Osteoarthritis: Mechanisms
- Mechanical - RC tear, AP instability, long head biceps tear
- Nutritional - inadequate diffusion, diminished synovial fluid
-
Rheumatoid Arthritis
- Systemic inflammatory disease of connective tissue
- Synovial inflammation of subacromial - sub deltoid bursa
- Symmetric involvement
- Painful abduction w/ shoulder to 90 degrees bilaterally
- Long term corticosteroid use → RC tear
-
AC Joint Arthrosis: Causes
- Degenerative (often seen w/ RC pathology or impingement)
- Post-traumatic (fall on outstretched arm)
-
AC Joint Arthrosis: Presentation
- C/O local pain (directly over AC joint)
- Pain w/ flexed-adducted position, over head motion
-
Adhesive Capsulitis: Types
Primary: idiopathic (insidious onset; unilateral)
- Secondary: associated w/ known condition
- Post traumatic (immobilization)
- Disease process (diabetes, post-mastectomy, RA, CVA/hemiplegia)
-
Adhesive Capsulitis: Mechanism
Trigger → inflammation of synovium & jt capsule → capsular fibrosis (collagen deposition) → decreased intra-articular volume/capsular compliance (humeral head tight against glenoid fossa) → global loss of AROM/PROM
-
Adhesive Capsulitis: Stages
- Stage I & II: Painful Stage - "Freezing"
- Progressive loss of motion w/ consistent pain
- Capsular pattern: ER → And → IR (global motion loss)
- Stage III: Adhesive Stage - "Frozen"
- Stiff restricted shoulder w/ minimal pain
- Compensatory motions - decreased inf. glide → shoulder hike
- Stage IV: Recovery Stage - "Thawing"
- Slow, gradual increase in ROM
- Recovery is spontaneous but frequently incomplete
-
Stability of GH Joint
Static components: capsular ligaments, labrum, intra-articular pressure
Dynamic components: rotator cuff, deltoid, long head of biceps
-
Complications of Instability
- Hill-Sachs Lesion
- Dislocation: compression fracture on posterior humeral head @ site of impact on inferior glenoid rim
- Subluxation: repetition of contact between humeral head & glenoid (lesion on posterior humeral head)
- Bankart Lesion:
- Avulsion of anterior inferior labrum from glenoid rim
Tears (RC, SLAP)
Impingement
-
Instability: Clinical Presentation
- Subjective reports of "clunk" or "click"
- Subjective reports of "dead arm" or general heaviness (SLAP)
- Diffuse soreness → multidirectional
- Pain location dependent on area of instability
-
Instability: Clinical Tests
- Sulcus Sign
- Posterior Instability
- Anterior Instability
- Apprehension
- Relocation
-
Impingement: Types
Primary: static (outlet impingement)
Secondary: dynamic, repetitive microtrauma (extrinsic)
-
Primary Impingement
- Static
- Subacromial outlet impingement (mechanical impingement of RC tendon beneath acromion; secondary to compromise of subacromial outlet space)
- *Subacromial outlet contains humeral head, acromion, coracromial arch & acromioclavicular ligament
- Causes:
- Acromion shape (curved or hooked)
- Acromioclavicular osteophytes
- Thickening of coracromial ligament
-
Primary Impingement: Classification
Neer's Three Stage Classification:
- Stage I: younger patients (<25); acute inflammation
- Stage II: ages 25-40; fibrosis and tendonitis
- Stage III: >age 40; partial/complete RC tear; osteophytes at coracromial arch
-
Primary Impingement: Clinical Presentation
Pain reported w/ forward flexion and IR position (elevation) -- greater tuberosity approximates acromion & coracromial arch
Typically older patients
-
Primary Impingement: Clinical Tests
- Neer Impingement
- Hawkins-Kennedy Impingement Test
-
Secondary Impingement
Dynamic: relative narrowing of outlet secondary to abnormal humeral head movement w/ activity
- Mechanism:
- → RC imbalance (weakness,tear)
- → Ligamentous instability
- Clinical Presentation:
- →Typically younger patients
- Symptoms activity specific (overhand activities)
-
Labral Tears: Types
- Type I: Fraying of labrum (degenerative)
- Type II: Detachment of superior labrum & origin LHB
- Type III: Bucket handle tear (labrum torn and displaced into joint)
- Type IV: Bucket handle that extends into biceps tendon
- *Type III and IV: linked to traumatic instability
- *Type II and IV: result in instability of biceps-labral anchor (more common!)
-
Mechanism of SLAP Injury
- Fall onto outstretched arm (FOOSH) - compression injury
- Traction tension on biceps tendon (LHB attaches to labrum in 50% of population)
-
Labral Tears: Clinical Tests
- Crank Test: (+) = symptomatic click or grinding or clunk
- O'Brien Test: (+) = relief of pain or popping w/ 2nd test position (sensitive and specific!)
- Biceps Load II: (+) = pain w/ resisted elbow flexion
-
Labral Tear: Clinical Presentation
- Biceps pain w/ elbow flexion
- Pain w/ overhead activities
- "Dead arm" when throwing
- Occasional popping/clicking in the shoulder
-
Rotator Cuff Tear: Mechanisms
- Compression (space attrition; instability → impingement)
- Tensile overload
- Macrotrauma
-
Rotator Cuff Tear: Clinical Tests
- Drop Arm Test
- Lift Off Test
- Belly-Press Test
- External Rotation Lag Sign
-
Bicipital Tendonitis
- LHB = attachment to labrum, SLAP
- → Stabilizes and decelerates in throwing
Mechanism → Tendonitis (impingement - passes beneath anterior edge of acromion
Subluxing LHB - tear of transverse humeral ligament
-
Bicipital Tendonitis: Clinical Tests
Speeds Test
-
Bursitis
- Primary - associated w/ systemic disease, degenerative changes
- Secondary - associated w/ other shoulder pathology (trauma, overuse)
- Clinical Presentation:
- → Empty end-feel (abduction = subacromial; ER = subcoracoid)
- → Painful arc
- → Non-capsular pattern
-
Acromioclavicular Joint Injury
Traumatic: fall on shoulder w/ arm adducted to side
-
Grades of AC Joint Sprain
1: Ligaments intact, (-) X-ray
- 2: A-C ligament tear, intact or sprained C-C ligaments
- →Clavicle unstable
- →AC space seen on X-ray
3: A-C and C-C ligament tear, downward displacement of acromion
4: Similar to type II w/ posterior clavicle dislocation
5, 6: Gross displacement of clavicle
-
Sternoclavicular Injuries
Traumatic: FOOSH (anterior dislocation more common than posterior)
- I: Intact ligaments, stable joint
- II: SC subluxation w/partial capsular and ligamentous disruption
- III: SC ligaments and capsule completely disrupted w/ anterior or posterior dislocation
-
Brachial Plexus
- Stretch/compression of c-spine (Stinger or Burner Syndrome)
- Burning or paresthesia throughout ambiguous dermatome distribution
- Transient loss of ROM and muscle weakness
-
Thoracic Outlet Syndrome: Definition and Mechansims
Compression of neural or vascular structures passing through thoracic outlet
- Mechanisms:
- → Primary = cervical rib, clavicle, scalenes
- → Secondary = postural variation
-
Thoracic Outlet Syndrome Presentation
- Numbness and tingling in hand
- Decreased circulation or "falling asleep" sensation in UE w/ overhead motions
- Pain in interscapular area, medial arm, forearm, hand
- TTP over scalenes
- Paresthesia w/ UE elevation
-
Thoracic Outlet Syndrome: Clinical Tests
|
|