Clinical Applications

Transcription

1 Unraveling the Mystery of Shoulder Pain #5: Clinical Applications Webinar Goal To stretch and challenge your ability to think critically and further develop your assessment skills. Time: 1 hour Schedule: Logistics Present a scenario You will respond to questions I pose General questions: 15 mins 1

2 Pretest 1. The supraspinatus is the strongest rotator cuff muscle. True or False? 2. The subscapularis is the primary muscle used in carrying a suitcase. True or False? 3. The infraspinatus is the primary lateral rotator of the humerus. True or False? 4. Adhesive capsulitis, traumatic arthritis of the shoulder and frozen shoulder all refer to the same condition. True or False? 5. The infraspinatus assists in abduction of the arm. True or False? 6. The scapulohumeral joint allows for 90 degrees of motion. True or False? Shoulder Webinar Clinical Applications Case #1 Try not go for the answer right away. Let s use our reasoning powers to go through the steps to figure these cases out. Clinical Scenario #1 Nine months ago my left shoulder started to hurt while doing normal things like reaching for items on my desk. That one started feeling a little better when four months ago my right arm and shoulder began to feel painful when raising my arm above my head and reaching backward. Now I can t even brush my hair. Both arms are painful but the right arm is worse. 2

3 Clinical Scenario #1: Positive tests Both arms: Passive elevation painful and very limited Passive lateral rotation painful and limited Passive medial rotation limited Passive scapulohumeral abduction slightly limited Right arm only: With the palm down, there is a painful arc, and she can only raise the arm to 145º. With the palm up, there is no painful arc, but she can still only raise the arm to 145º. Resisted medial rotation is painful and weak. All other resisted tests of the biceps, triceps, supraspinatus, and infraspinatus are weak. Clinical Scenario #1: Test results Passive elevation painful and very limited Clinical Scenario #1: Test results Passive lateral rotation painful and limited 3

4 Clinical Scenario #1: Test results Passive medial rotation limited Clinical Scenario #1: Test results Passive scapulohumeral abduction slightly limited Clinical Scenario #1: Test results Painful arc with the palm down (can only raise the arm to 145º) 4

5 Clinical Scenario #1: Test results With the palm up, there is no painful arc (can only raise the arm to 145º) Clinical Scenario #1: Test results Resisted medial rotation on the right is painful and weak Clinical Scenario #1: Test results All other resisted tests are weak on the right 5

6 Clinical Scenario #1: Both Arms Passive elevation: painful and very limited Passive medial rotation: limited Passive lateral rotation: painful and limited Passive scapulohumeral abduction: slightly limited Clinical Scenario #1: Right arm only Painful arc on the right with the palm down. But she can only raise the arm to 145. Resisted medial rotation is painful and weak When the palm is turned toward the ceiling, there is no painful arc. (can only raise the arm to 145º) All other resisted tests of the biceps, triceps, Supraspinatus, and infraspinatus are weak Clinical Scenario #1: Questions 1. How many injuries do you think there are? Why? 2. Based on the painful passive tests, where is the problem? 3. Why are so many of the muscles on the right weak? 4. The painful resisted test tells you what? 5. Why is there no painful arc when the palm is facing up? 6

7 Clinical Scenario #1: Questions What are the injuries? Questions? Clinical Scenario #2 My shoulder began to hurt me about six months ago after a trip to Yellowstone National Park for a vacation. When I returned I noticed it was difficult to grab my computer case in the back of the car. I would get a twinge of pain if I tried. Sometimes when I lie on my shoulder at night it hurts and sometimes it doesn't. When I reach for something on the top shelf it s a little painful, and playing racquetball hurts after a few minutes so I stopped doing that. 7

8 Clinical Scenario #2: Positive tests Passive elevation hurts Passive medial rotation hurts Passive adduction hurts Resisted abduction hurts Resisted medial rotation only hurts if tested from the 180 degree position with an overpressure at the end. Clinical Scenario #2: Test results Passive elevation hurts Clinical Scenario #2: Test results Passive medial rotation hurts 8

9 Clinical Scenario #2: Test results Passive adduction hurts Clinical Scenario #2: Test results Resisted abduction hurts Clinical Scenario #2: Test results Resisted medial rotation only hurts if tested from the 180 degree position with an overpressure at the end. 9

10 Clinical Scenario #2: Test results Passive elevation hurts Resisted abduction hurts Passive medial rotation hurts Passive adduction hurts Resisted medial rotation only hurts if tested from the 180 degree position with an overpressure Clinical Scenario #2: Questions 1. What does the term major indicator mean? 2. Which tests are the major indicator(s)? 3. What do the auxiliary indicators tell you? 4. What structure is injured? 5. What does pain on passive adduction tell you? 6. What does pain on elevation tell you? Questions? 10

11 Clinical Scenario #3 I'm right handed and when I swung a bat in the softball game a few months ago it started to hurt in my left shoulder. I thought it would go away so I kept playing but it got worse as the game went on. It s sometimes painful when I lie on that side at night but not always. When I take off my V-neck sweater overhead that's really painful. Sometimes it even hurts when I write. Clinical Scenario #3 The first time through the tests there was no pain. Then I did them a second time and found: Resisted lateral rotation was painful only in a laterally rotated position. Passive medial rotation was painful at the very end Passive elevation was painful. Clinical Scenario #3 Resisted lateral rotation was painful only in a laterally rotated position. 11

12 Clinical Scenario #3 Passive medial rotation was painful at the very end. Clinical Scenario #3 Passive elevation was painful. Clinical Scenario #3 Resisted lateral rotation was painful only in a laterally rotated position. Passive medial rotation was painful at the very end. Passive elevation was painful. 12

13 Clinical Scenario #3: Questions 1. What muscle is used when swinging a bat if you're right-handed? 2. What does it mean that the left shoulder began to hurt? 3. Why was passive medial rotation painful? 4. What does pain on passive elevation tell you in this instance? 5. Which structure is injured? 6. What part of it is injured? Questions Facebook.com/DrBenBenjamin Post-test 1. The supraspinatus is the strongest rotator cuff muscle. True of False 2. The subscapularis is the primary muscle used in carrying a suitcase. True of False 3. The infraspinatus is the primary lateral rotator of the humerus. True of False 4. Adhesive capsulitis, traumatic arthritis of the shoulder and frozen shoulder all refer to the same condition. True of False 5. The infraspinatus assists in abduction of the arm. True of False 6. The scapulohumeral joint allows for 90 degrees of motion. True of False 13