Orthopedics Shoulder

Question 1

Why Teach Musculoskeletal Medicine to PCPs?

• >40 million Americans have musculoskeletal (MSK) disorders.
• MSK complaints
• __-__% of all visits to a PCP
• __% of all new MSK injuries are treated by PCPs
• While ~90% of common nonsurgical MSK complaints are thought to be manageable in the PCP setting, many of these patients are referred to a specialist due to lack of ______ with MSK diagnoses.
• Documented lack of tr______ in MSK disorders

Answer 1

• >40 million Americans have musculoskeletal (MSK) disorders.
• MSK complaints
• 10-15% of all visits to a PCP
• 70% of all new MSK injuries are treated by PCPs
• While ~90% of common nonsurgical MSK complaints are thought to be manageable in the PCP setting, many of these patients are referred to a specialist due to lack of comfort with MSK diagnoses.
• Documented lack of training in MSK disorders

Question 2

Common Physical Exam Principles

• Same framework whether or not you are doing a cardiac exam or a shoulder exam.
• All 5 _____ (well, not taste, although recall diabetes!)
• (4) Components

Answer 2

• Same framework whether or not you are doing a cardiac exam or a shoulder exam.
• All 5 senses (well, not taste, although recall diabetes!)
• 4 Components
  
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

Question 3

Inspection

• Before you “lay on the _____”
• Mostly v_____, but also can be smell or hearing
• Look for s_______ (especially in MSK)
• Differences size (sw_____?), color (___ness/br______?), obvious differences in range of _______, g___, etc.

Answer 3

• Before you “lay on the hands”
• Mostly visual, but also can be smell or hearing
• Look for symmetry (especially in MSK)
• Differences size (swelling?), color (redness/bruising?), obvious differences in range of motion, gait, etc.

Question 4

Palpation

• Your _____ are your most important tools
• Palpate _____ areas last
• Examine the _____ side first
• Assess for: _____ness, tem______, tex____, pul______, ma____, moi_____, ela______
• C______ is an MSK-specific aspect of the exam that falls under palpation
• Crepitus: a gr_____sound or sensation produced by f_____ between (1) and (1) or the fr______ parts of a bone

Answer 4

• Your hands are your most important tools
• Palpate tender areas last
• Examine the normal side first
• Assess for: tenderness, temperature, texture, pulsations, masses, moisture, elasticity
• Crepitus is an MSK-specific aspect of the exam that falls under palpation
• Crepitus: a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone

Question 5

Percussion

• Direct v. Indirect
  
  • _______: 2 fingers directly tapping over the body region
    
    • e.g. sinuses
  • _______: Usually your middle finger is placed firmly over the exam region and your other middle finger strikes your stationary finger
    
    • e.g. abdomen, chest
• Not so much for the general orthopedic exam
  
  • …although if percussion elicits pain, you might want to consider an MSK diagnosis in your differential.

Answer 5

• Direct v. Indirect
  
  • Direct: 2 fingers directly tapping over the body region
    
    • e.g. sinuses
  • Indirect: Usually your middle finger is placed firmly over the exam region and your other middle finger strikes your stationary finger
    
    • e.g. abdomen, chest
• Not so much for the general orthopedic exam
  
  • although if percussion elicits pain, you might want to consider an MSK diagnosis in your differential.

Question 6

Auscultation

• ______ used in orthopedics
• However, joints can be auscultated and _______ that is not able to be felt or heard can be discovered (unfortunately not very clinically useful)
• Rarely, crepitus is loud enough to be heard without a ________

Answer 6

• Rarely used in orthopedics
• However, joints can be auscultated and crepitus that is not able to be felt or heard can be discovered (unfortunately not very clinically useful)
• Rarely, crepitus is loud enough to be heard without a stethoscope

Question 7

Some notes on a focused MSK HPI

• Chief Complaint
• _______
  
  • Body Part
  • Unilateral or bilateral?
  • Focused or Diffuse?
• _______
  
  • Trauma or No Trauma?
  • Acute or Chronic?
• ______
  
  • Constant or Intermittent?
  • Getting Better or Worse?
  • Worse in the morning or end of day?
• _________
  
  • Sharp or Dull?
• ________
  
  • Pain Score; 0 - 10
• Context
  
  • Better with rest?
  • Worse with activity?
• ________ Factors
  
  • What makes it better/worse?
• Other/_______ Signs and Symptoms
  
  • Focal weakness/numbness? (usually spine)
  • Bowel or bladder symptoms? (spine)
  • Gait, balance, fine motor control (spine)

Answer 7

• Chief Complaint
• Location
  
  • Body Part
  • Unilateral or bilateral?
  • Focused or Diffuse?
• Duration
  
  • Trauma or No Trauma?
  • Acute or Chronic?
• Timing
  
  • Constant or Intermittent?
  • Getting Better or Worse?
  • Worse in the morning or end of day?
• Quality
  
  • Sharp or Dull?
• Severity
  
  • Pain Score; 0 - 10
• Context
  
  • Better with rest?
  • Worse with activity?
• Modifying Factors
  
  • What makes it better/worse?
• Other/Associated Signs and Symptoms
  
  • Focal weakness / numbness? (usually spine)
  • Bowel or bladder symptoms? (spine)
  • Gait, balance, fine motor control (spine)

Question 8

Normal Anatomy: Shoulder

Answer 8

Question 9

Normal Anatomy: Shoulder

Answer 9

Question 10

Normal Anatomy: Shoulder

Answer 10

Question 11

PE: Shoulder

General

• The patient is in no acute d______, m_____ and af_____ are appropriate, alert and oriented times three.
• The patient is ambulating with a smooth and symmetric g____ putting full w_____ on both lower extremities with good co__________ and ba______.

Answer 11

• The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
• The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.

Question 12

PE: Shoulder

Head/Neck: Inspection

• Head is at______/_____cephalic.
• Both shoulders appear s______.
• S_____ is intact about both shoulders without erythema.
• There is no ______ neck _______ to palpation about the neck, and full neck _ _ __
• Warm and well-_______ distally

Answer 12

• Head is atraumatic/normocephalic.
• Both shoulders appear symmetric.
• Skin is intact about both shoulders without erythema.
• There is no focal neck tenderness to palpation focally about the neck, and full neck range of motion.
• Warm and well-perfused distally

Question 13

PE: Shoulder

Shoulder

• Tenderness to palpation
  
  • Where?
  • Anterior ______ / AC joint?
• Range of motion
  
  • Forward elevation to ~___-degrees
  • External rotation to ~__-degrees
  • Internal rotation to the upper ______ level (reaching behind the back)
• Strength
  
  • Shoulder as well as distally with ______ IP flexion, _____ abduction/adduction, and ______ extension.
• Sensation
  
  • Intact to _____ touch distally without any focal ____ness or t______.
• Stability
  
  • Instability is noted.
• Special Tests
  
  • App_______ test. (anterior instability)
  • ________ signs. (bursitis, impingement, cuff)
  • ____-arm. (cuff)
  • ______ body. (AC joint)
  • _____ press. (subscap)
  • O’______ (labrum)

Answer 13

• Tenderness to palpation
  
  • Where?
  • Anterior acromiom / AC joint?
• Range of motion
  
  • Forward elevation to ~180-degrees
  • External rotation to ~45-degrees
  • Internal rotation to the upper lumbar level (reaching behind the back)
• Strength
  
  • Shoulder as well as distally with thumb IP flexion, finger abduction/adduction, and index extension.
• Sensation
  
  • Intact to light touch distally without any focal numbness or tingling.
• Stability
  
  • Instability is noted.
• Special Tests
  
  • Apprehension test. (anterior instability)
  • Impingement signs. (bursitis, impingement, cuff)
  • Drop-arm. (cuff)
  • Cross body. (AC joint)
  • Belly press. (subscap)
  • O’Brien (labrum)

Question 14

Bursitis/Impingement/Rotator Cuff Tendonitis

• ______ common
• Rotator cuff tendons travel through a ______ space
• Impingement can be caused by the ______ of the acromion / rubbing of the _____ on the bursa and the cuff tendons
• _______ tendonitis also common: calcium deposits within tendons of rotator cuff

Answer 14

• Very common
• Rotator cuff tendons travel through a narrow space
• Impingement can be caused by the shape of the acromion / rubbing of the bone on the bursa and the cuff tendons
• Calcific tendonitis also common: calcium deposits within tendons of rotator cuff

Question 15

Bursitis / Impingement: Diagnosis

History

• Often traumatic?
• Pain often at rest, but worse with ______, especially what motion?
• _______ shoulder pain (in the region of the acromion), often radiating ____ the arm but typically ___ below the elbow
• Pain is often bad at _____ / sl______ difficulties
• Decreased strength and range of motion possible (pain) → c_______ with cuff tear

Answer 15

• Often atraumatic
• Pain often at rest, but worse with motion, especially forward elevation
• Anterior shoulder pain (in the region of the acromion), often radiating down the arm but typically not below the elbow
• Pain is often bad at night / sleeping difficulties
• Decreased strength and range of motion possible (pain) → confusion with cuff tear

Question 16

Bursitis/Impingement/Tendinitis Diagnosis

Physical

• Key abnormal finding is pain where?
• Worse with (1), especially _______ forward elevation (“_________ signs”)
• Neer impingement test =
• ROM usually ________

Answer 16

• Key abnormal finding is pain over the region of the anterior acromion
• Worse with forward elevation, especially resisted forward elevation (“impingement signs”)
• Neer impingement test (pain in region of acromion on FE)
• ROM usually normal

Question 17

Bursitis/Impingement Imaging

XR:

• Result?
• May show a bone _____, especially on a _______-Y view
• Bone spur is often thought to be ________ of the coracoacromial ______

MR:

• _______ required in initial phases
• F_____/In________ in the bursa and cuff
• Sometimes partial cuff _____

Answer 17

XR:

• Result?
• May show a bone spur, especially on a Scapular-Y view
• Bone spur is often thought to be calcification of the coracoacromial ligament

MR:

• Rarely required in initial phases
• Fluid / Inflammation in the bursa and cuff
• Sometimes partial cuff tears

Question 18

Bursitis/Impingement: Treatment

• GOAL
  
  • Reduce ____ / Restore ______
  • Can take several _____ to ______
• Almost _____ non-surgical
  
  • R____
  • N_____s (oral or topical)
  • P _
  • In______
• Surgery
  
  • _________ decompression
    
    • Remove (1), make more _____ for the cuff
• Refer?
  
  • Significant loss of _____ (esp if trauma related)
  • No improvement after full course of ________ options

Answer 18

• GOAL
  
  • Reduce pain / Restore function
  • Can take several weeks to months
• Almost always non-surgical
  
  • Rest
  • NSAIDs (oral or topical)
  • PT
  • Injection
• Surgery
  
  • Subacromial decompression
    
    • Remove bone spur, make more room for the cuff
• Refer?
  
  • Significant loss of ROM (esp if trauma related)
  • No improvement after full course of conservative options

Question 19

Shoulder Instability (Dislocation/Labral Tear)

• Much _____ inherent stability than other joints
  
  • Golf ball on a golf tee
• Generalized ligamentous/soft tissue l______?
  
  • _______directional instability (anterior or multidirectional?)
  • Generally not a s_______ issue
• Related to a trauma?
  
  • ____-time dislocation?
  • ______ dislocations?
• Rule-of-thumb
  
  • Younger patients who dislocate → (1) tear
  • Older patients who dislocate → (1) tear

Answer 19

• Much less inherent stability than other joints
  
  • Golf ball on a golf tee
• Generalized ligamentous / soft tissue laxity?
  
  • Multidirectional instability (anterior or multidirectional?)
  • Generally not a surgical issue
• Related to a trauma?
  
  • One-time dislocation?
  • Chronic dislocations?
• Rule-of-thumb
  
  • Younger patients who dislocate → Labral tear
  • Older patients who dislocate → Rotator cuff tear

Question 20

Shoulder Instability

• Labrum =

Answer 20

• Labrum (soft tissue that stabilizes shoulder joint) provides extra support - if labrum is torn during dislocation , shoulder will not be stable

Question 21

Shoulder Dislocation Diagnosis

History

• Typically _______ (but sometimes with only minimal trauma).
• _______ dislocation is much more common than _______ dislocation (97%).
• “______ position” - baseball pitch (Hyper-__duction/ER = ____ _____)

Answer 21

• Typically traumatic (but sometimes with only minimal trauma).
• Anterior dislocation is much more common than posterior dislocation (97%).
• “Throwing position” - baseball pitch (Hyper-Abduction/External Rotation)

Question 22

Shoulder Dislocation Diagnosis

Physical

• P____
• Often loss of con_____ of the shoulder (not always with high BMI)
• ________ ROM, especially rotation
• Sometimes ____ness

Answer 22

• Pain
• Often loss of contour of the shoulder (not always with high BMI)
• Decreased ROM, especially rotation
• Sometimes numbness

Question 23

Shoulder Dislocation Imaging

Where is the ball in relation to the socket?

Answer 23

Ball in front of socket

Question 24

Shoulder Dislocation Imaging

Pearls

• ______ view is mandatory in order to rule out a ______ dislocation
• Always need to study x-rays to rule out an associated proximal _______ fracture. (stat __ if unsure _______ reduction)

Answer 24

• Axillary view is mandatory in order to rule out a posterior dislocation
• Always need to study x-rays to rule out an associated proximal humerus fracture. (stat CT if unsure BEFORE reduction)
• axial view = beam is directed into axilla from below

Question 25

Shoulder Dislocation: 2 terms ## Footnote * **\_\_\_\_\_-\_\_\_\_\_ Deformity**: *in the process of dislocation, ball impacts the anterior part of the glenoid* * Posterolateral cortical impaction fracture (humeral head) * **\_\_\_\_\_\_ lesion** * Anteroinferior labrum *(breaks off during dislocation)* * Soft tissue v. bony

Answer 25

* **Hill-Sachs Deformity**: *in the process of dislocation, ball impacts the anterior part of the glenoid* * Posterolateral cortical impaction fracture (humeral head) * **Bankart lesion** * Anteroinferior labrum *(breaks off during dislocation)* * Soft tissue v. bony

Question 26

Shoulder Dislocation: Closed Reduction * Misconception =* * ​*Steps of reduction (youtube vid) 1. Take elbow and forearm and ____ slowly to __ degree \_\_\_duction 2. Slowly \_\_\_rotate the arm while keeping the 90d abduction 3. Apply progressive \_\_\_duction in sight \_\_\_\_version until the dislocation resolves

Answer 26

* Actudally does not require alot of force* * ​*Steps of reduction (youtube vid) 1. Take elbow and forearm and lift slowly to 90 degree abduction 2. Slowly exorotate the arm while keeping the 90d abduction 3. Apply progressive adduction in sight anteversion until the dislocation resolves

Question 27

Bankart Repair =

Answer 27

A Bankart repair is a surgical procedure to prevent recurring anterior shoulder dislocations due to instability in the back of the shoulder. The most common form of shoulder ligament injury is the Bankart lesion, where the ligaments are torn from the front of the socket. ## Footnote *Screws, anchors, and sutures*

Question 28

Shoulder Dislocation: Treatment ## Footnote * Reduction * \_\_\_\_\_-Reduction X-Rays (or _ \_ if concern for fracture) * S\_\_\_\_ (3-4 weeks) * Rest / Ice / NSAIDs * No external rotation past n\_\_\_\_\_\_ and no abduction past \_\_\_-degrees for ~\_-\_weeks * PT * If recurrent → _ \_ _ (to rule-out cuff or labral injury) * Appropriate to refer to MSK specialist, especially in cases of re\_\_\_\_\_ dislocation and fracture or s\_\_\_\_ t\_\_\_\_\_\_ injury * *\_\_\_\_\_\_\_\_\_ is the speciality of orthopedic surgery, like cardiology to cardiac surgery*

Answer 28

* Reduction * Post-Reduction X-Rays (or CT if concern for fracture) * Sling (3-4 weeks) * Rest / Ice / NSAIDs * No external rotation past neutral and no abduction past 90-degrees for ~4-6 weeks * PT * If recurrent → MRI (to rule-out cuff or labral injury) * Appropriate to refer to MSK specialist, especially in cases of recurrent dislocation and fracture or soft tissue injury * *Physiatrist is the speciality of orthopedic surgery, like cardiology to cardiac surgery*

Question 29

Rotator Cuff Tear ## Footnote * Very _______ cause of **pain** and **disability** * ~2 million visits/yr in the U.S. for rotator cuff problems * Not always traumatic * Age (1) → traumatic * Age, \>\_\_\_ → degenerative / non-traumatic * Repetitive s\_\_\_\_\_, bone \_\_\_\_, _____ supply * Shoulder → Minimal bony constraint * Rotator cuff is a major soft tissue st\_\_\_\_\_\_

Answer 29

* Very common cause of pain and disability * ~2 million visits/yr in the U.S. for rotator cuff problems * Not always traumatic * Young → traumatic * Old(er), \>40 → degenerative / non-traumatic * Repetitive stress, bone spurs, blood supply * Shoulder → Minimal bony constraint * Rotator cuff is a major soft tissue stabilizer

Question 30

Rotator Cuff Anatomy ## Footnote **S-I-T-S**

Answer 30

**Supraspinatus (most commonly torn)** **Infraspinatus** **Teres minor** **Subscapularis**

Question 31

Rotator Cuff Diagnosis ## Footnote **History** * Trauma v. No Trauma? * Common presenting symptoms: * Pain * ______ pain (in the region of the acromion), often ______ down the arm but typically not below the \_\_\_\_\_ * Often at ____ and especially with what motion? (1) * Weakness * ______ range of motion - *unlike bursitis, you may have to assist and watch for what sign? (1)* * Difficulty with ADLs * Pain at n\_\_\_\_

Answer 31

* Trauma v. No Trauma? * Common presenting symptoms: * Pain * Anterior pain (in the region of the acromion), often radiating down the arm but typically not below the elbow * Often at rest and especially with forward elevation * Weakness * Decreased range of motion - *unlike bursitis, you may have to assist and watch their arm drop down (drop arm sign)* * Difficulty with ADLs * Pain at night

Question 32

Rotator Cuff Tear Diagnosis Physical * Pain over ______ acromion, positive ________ signs, decreased _ \_ \_ * \_\_\_\_\_ness * Possible \_\_\_-\_\_\_ sign

Answer 32

* Pain over anterior acromion, positive impingement signs, decreased range of motion * Weakness * Possible drop-arm sign

Question 33

Rotator Cuff Tear Drop Arm Sign Positive sign?

Answer 33

When slowly bringing arm down and it all of a sudden drops = positive sign

Question 34

Rotator Cuff Tear Imaging ## Footnote * XR: * Often normal * May show a bone \_\_\_\_, especially on a Scapular-\_\_ view * Bone spur is often thought to be _______ of the coracoacromial \_\_\_\_\_\_ * MR: * (1) for diagnosis * Not usually ordered initially, especially for chronic tears

Answer 34

* XR: * Often normal * May show a bone spur, especially on a Scapular-Y view * Bone spur is often thought to be calcification of the coracoacromial ligament * MR: * Gold standard for diagnosis * Not usually ordered initially, especially for chronic tears

Question 35

Rotator Cuff Treatment ## Footnote * GOAL * Reduce pain / Restore function * Chronic * Almost always ___ to start with a non-surgical approach (80% treated non-op) - *usually not a rush* * R\_\_\_\_ * N\_\_\_\_\_s (oral or topical) * P \_ * I\_\_\_\_\_\_\_ * Acute tears with pain and decreased ROM → \_\_\_\_\_\_ * Refer? * Significant loss of _ \_ _ (esp if trauma related) * A\_\_\_\_ injuries

Answer 35

* GOAL * Reduce pain / Restore function * Chronic * Almost always OK to start with a non-surgical approach (80% treated non-op) - *usually not a rush* * Rest * NSAIDs (oral or topical) * PT * Injection * Acute tears with pain and decreased ROM → surgery * Refer? * Significant loss of ROM (esp if trauma related) * Acute injuries

Question 36

Adhesive Capsulitis (Frozen Shoulder) ## Footnote * Decreased range of motion * _____ = _____ *diagnosis* * \> in what gender? * \_\_- __ years-old * Higher risk in \_\_\_\_\_\_\_ * Also hyper and hypo\_\_\_\_\_, P\_\_\_\_\_’s, and ca\_\_\_\_ disease * Can be idiopathic, post-traumatic, or post-surgical * Pathoanatomy: * ______ process causes \_\_\_\_\_blastic proliferation of joint capsule → th\_\_\_\_\_, fi\_\_\_\_\_, and ad\_\_\_\_\_\_ of the capsule to itself and the humerus (causes a mechanical ______ to motion) * **(1) how does it resolve**, but full recovery may take up to 3-years (!)

Answer 36

* Decreased range of motion * Active = Passive *diagnosis* * Women \> Men * 40 - 60 years-old * Higher risk in diabetics * Also hyper and hypothyroid, Parkinson’s, and cardiac disease * Can be idiopathic, post-traumatic, or post-surgical * Pathoanatomy: * Inflammatory process causes fibroblastic proliferation of joint capsule → thickening, fibrosis, and adherence of the capsule to itself and the humerus (causes a mechanical block to motion) * Self-limiting, but full recovery may take up to 3-years (!)

Question 37

Adhesive Capsulitis Diagnosis ## Footnote History * Often in\_\_\_\_\_\_/gradual onset * Pain (often a ____ ache) before any loss of motion Stages: * **(1)**: 6-9 months, pain worsens and ROM decreases * **(1)**: 4-6 months, pain improves but loss of motion remains * **(1)**: 6 months - 3 years, pain and ROM improve

Answer 37

* Often insidious / gradual onset * Pain (often a dull ache) before any loss of motion Stages: * Freezing: 6-9 months, pain worsens and ROM decreases * Frozen: 4-6 months, pain improves but loss of motion remains * Thawing: 6 months - 3 years, pain and ROM improve

Question 38

Adhesive Capsulitis Diagnosis ## Footnote **Physical** * **Hallmark**: ______ loss of _____ (\_\_\_\_= \_\_\_\_\_) * Examine patient in what position? * Limitations may be slight (examine contralateral) * ____ rotation deficit is the most common finding * “Te\_\_\_\_\_\_” or fixed endpoint * Note: the symmetric loss of motion is how you distinguish frozen shoulder from a cuff tear * In a cuff tear, active ROM is ______ but passive ROM is \_\_\_\_

Answer 38

* **Hallmark**: symmetric loss of motion (Active = Passive) * Examine supine (or semi-supine) * Limitations may be slight (examine contralateral) * ER deficit is the most common finding * “Tethered” or fixed endpoint * Note: the symmetric loss of motion is how you distinguish frozen shoulder from a cuff tear * In a cuff tear, active ROM is limited but passive ROM is full

Question 39

Adhesive Capsulitis Imaging ## Footnote * XR: * Usually \_\_\_\_\_\_ * MR: * Rarely required or helpful * BUT usually obtained due to the pro\_\_\_\_\_\_\_ course of this entity * Can be helpful in diagnosing associated injuries such as a (1) but the results would be unlikely to alter the course of the treatment

Answer 39

* XR: * Usually normal * MR: * Rarely required or helpful * BUT usually obtained due to the prolonged course of this entity * Can be helpful in diagnosing associated injuries such as a cuff tear but the results would be unlikely to alter the course of the treatment

Question 40

Adhesive Capsulitis Treatment ## Footnote * GOAL * Reduce pain, restore function / range of motion * Can take up to __ years... * Almost always non-surgical * **(1)\*** ***is the key*** * Home exercises /st\_\_\_\_\_ * N\_\_\_\_\_s (oral or topical) * In\_\_\_\_\_\_\_\_ * Surgery * ____ resort, mixed results * De\_\_\_\_\_\_\_ of capsular adhesions * Man\_\_\_\_\_\_\_ under anesthesia * Refer? * No improvement with initial round of _ \_ * Active ROM = Passive ROM

Answer 40

* GOAL * Reduce pain, restore function / range of motion * Can take up to 3-years... * Almost always non-surgical * **Aggressive PT\*** ***is the key*** * Home exercises / stretches * NSAIDs (oral or topical) * Injection * Surgery * Last resort, mixed results * Debridement of capsular adhesions * Manipulation under anesthesia * Refer? * No improvement with initial round of PT * Active ROM = Passive ROM

Question 41

Biceps Pathology and SLAP Tear * Normal “\_\_\_\_ and \_\_\_\_\_” * Re\_\_\_\_\_\_\_ motions associated with j\_\_\_ or sp\_\_\_\_\_ (especially overhead activities) * Anatomy: * Biceps, 2 “heads” * (1): through bicipital groove, into joint, attaches to / confluent with superior labrum * (1): coracoid

Answer 41

* Normal “wear and tear” * Repetitive motions associated with jobs or sports (especially overhead activities) * Anatomy: * Biceps, 2 “heads” * Long Head: through bicipital groove, into joint, attaches to / confluent with superior labrum * Short Head: coracoid (not pictured)

Question 42

SLAP Tear ## Footnote **SLAP =**

Answer 42

**Superior Labrum, Anterior Posterior**

Question 43

Biceps Diagnosis ## Footnote History * **P\_\_\_\_ or \_\_\_\_\_ness in region of ______ groove** * Worse with activity, especially \_\_\_\_\_head lifting * Often pain radiating _____ the arm (distribution of biceps) * Can be very similar to impingement / cuff symptoms * Occasional ________ sensation in region of **bicipital** groove or shoulder

Answer 43

* **Pain or tenderness in region of bicipital groove** * Worse with activity, especially overhead lifting * Often pain down the arm (distribution of biceps) * Can be very similar to impingement / cuff symptoms * Occasional snapping sensation in region of **bicipital** groove or shoulder

Question 44

Biceps Pathology Diagnosis Physical * \_\_\_\_\_\_\_ness in region of bicipital groove * Usually ____ ROM * Special test: * **(1)**: *describe the test,* *what is a positive test?* * **\_\_\_\_\_\_\_ deformity** → rupture

Answer 44

* Tenderness in region of bicipital groove * Usually full ROM * Special test: * **O’Brien test**: *elevate arm with thumb pointing up, resist their arm and no pain, but if you have them but their arm down and presence of pain = positive test* * **Popeye deformity** → rupture

Question 45

Biceps/SLAP Tear Imaging * XR: * Usually \_\_\_\_\_ * Ultrasound: * Can show _____ tendon within bicipital groove (rarely ordered for diagnosis) * Useful for guided \_\_\_\_\_\_ * MR / MR Arthrogram: *dye injected before MRI - will ___ space of tear* * **(1)**: thickening and tenosynovitis * **(1)**: gold standard for diagnosis

Answer 45

* XR: * Usually normal * Ultrasound: * Can show thickened tendon within bicipital groove (rarely ordered for diagnosis) * Useful for guided injection * MR / MR Arthrogram: *dye injected before MRI - will fill space of tear* * **Bicipital tendonitis**: thickening and tenosynovitis * **SLAP**: gold standard for diagnosis

Question 46

Biceps/SLAP Tear Treatment ## Footnote * GOAL * Reduce \_\_\_, restore \_\_\_\_\_\_ * Bicipital tendonitis: * Almost always non-surgical (recalcitrant → biceps \_\_\_\_\_\_) * PT * Home exercises * NSAIDs (oral or topical) * Injection (\_ _ guided) * SLAP: * Often non-surgical but if recalcitrant, can be de\_\_\_\_\_ or re\_\_\_\_\_ (depending on type of tear) * Refer? * No improvement with initial round of _ \_

Answer 46

* GOAL * Reduce pain, restore function * Bicipital tendonitis: * Almost always non-surgical (recalcitrant → biceps tenodesis) = *ortho* *surgery that repairs the tendon that connects your bicep to your shoulder* * PT * Home exercises * NSAIDs (oral or topical) * Injection (U/S guided) * SLAP: * Often non-surgical but if recalcitrant, can be debrided or repaired (depending on type of tear) * Refer? * No improvement with initial round of PT

Question 47

Shoulder Arthritis ## Footnote * Much ____ common than knee / hip arthritis * Arthritis: * Technically means ________ **of a joint** * Many types, but the end-stage is the same for all → ________ joint disease where the s\_\_\_\_\_\_ c\_\_\_\_\_\_ has worn down * Can you rebuild worn cartilage? * More common in people \>\_\_\_, what gender (1), and individuals with prior dis\_\_\_\_\_\_\_

Answer 47

* Much less common than knee / hip arthritis * Arthritis: * Technically means **inflammation of a joint** * Many types, but the end-stage is the same for all → degenerative joint disease where the synovial cartilage has worn down * No way to rebuild worn cartilage * More common in people \>60, women, and individuals with prior dislocation

Question 48

Shoulder Arthritis Diagnosis ## Footnote History * Shoulder pain, worse with \_\_\_\_\_/ range of \_\_\_\_\_ * Often no pain at \_\_\_\_ * Loss of range of motion * _____ rotation * _____ pain / difficulty sl\_\_\_\_\_\_\_

Answer 48

* Shoulder pain, worse with activity / range of motion * Often no pain at rest * Loss of range of motion * External rotation * Night pain / difficulty sleeping

Question 49

Shoulder Arthritis Diagnosis ## Footnote Physical * Key abnormal finding is (1) * Rotation is typically more affected * BUT, many active patients can have surprisingly ____ ROM * Mechanical symptoms * C\_\_\_\_\_\_, ca\_\_\_\_\_, “s\_\_\_\_\_\_”

Answer 49

* Key abnormal finding is decreased ROM * Rotation is typically more affected * BUT, many active patients can have surprisingly full ROM * Mechanical symptoms * Crepitus, catching, “squeaking”

Question 50

Shoulder Arthritis Imaging ## Footnote * XR: * **(1)** *(bone on bone)* * **(1)** *(bony outgrowth asctd with degeneration of cartilage joints)* * Subchondral **(1)** *(whitening on xray* / **(1)** *(areas of lucency where fluid has accumulated in joint space)* * Posterior glenoid wear * MR/CT: * Surgical planning tools

Answer 50

* XR: * Joint space narrowing *(bone on bone)* * Osteophytes *(bony outgrowth asctd with degeneration of cartilage joints)* * Subchondral sclerosis *(whitening on xray* / cysts *(areas of lucency where fluid has accumulated in joint space)* * Posterior glenoid wear * MR/CT: * Surgical planning tools

Question 51

Shoulder Arthritis Treatment ## Footnote * GOAL * Reduce \_\_\_\_/ Restore \_\_\_\_\_\_ * Non-surgical * Rest * NSAIDs (oral or topical) * PT * Injection * Surgery * **(1)** (Intact rotator cuff) * **(1)** (Deficient cuff but intact deltoid) * **\_\_\_\_\_\_ debridement procedures** (e.g. arthroscopic debridement) are r\_\_\_\_\_ appropriate, as they do not address the underlying pathology and are, at best, t\_\_\_\_\_\_\_ measures * Refer? * Significant loss of _ \_ \_ * No improvement after full course of conservative options

Answer 51

* GOAL * Reduce pain / Restore function * Non-surgical * Rest * NSAIDs (oral or topical) * PT * Injection * Surgery * **Total shoulder arthroplasty** (Intact rotator cuff) * **Reverse total shoulder arthroplasty** (Deficient cuff but intact deltoid) * **Limited debridement procedures** (e.g. arthroscopic debridement) are rarely appropriate, as they do not address the underlying pathology and are, at best, temporizing measures * Refer? * Significant loss of ROM * No improvement after full course of conservative options