Diagnosis AC Separation

Pain Location/Mechanism Superior Truamatic

Specifics to Dx Direct Fall on: *ShoulderTip *Outstretched Hand *Flexed Elbow

Inspection Ossious Palp *Step Defect *Dropped *AC Joint Pain and Shoulder *Edema increased joint space. and/or Ecchymosis (w/trauma). *Unilaterally depressed scapula.. *Elevated distal clavicle.

Soft Tissue Palp ROM PTE: *Coraco- *Painfull ABduction Clavicular Lig *AC Lig Pain. *Decreased A/P ROM (II/III)

Special Test * Weighted X-ray - reveals seperation of the clavicle and AC (Type II/II) joint space above normal ranges. *Compression @ AC *Distraction @AC *Sulcus Sign . *Sulcus Test

Diff Dx

Shoulder Pointer?????

Superior Traumatic

Direct Fall on: *ShoulderTip

* Ecchymosis Edema/Swelling

*Pain over the AC joint

PTE: Clavicular Lig

*Coraco- *Limited Abduction *AC Lig Pain.

Clavicular Fracture

Superior Traumatic

Direct Impact to Shoulder

*Dropped Shoulder *Edema over Clavicle *Ecchymosis

*Tender/Painful Clavicle * Swelling of the surrounding *Clavicle deformity *Old connective tissues. - Callus Formation * Tenderness and Pain of Surrounding mm (pec major, SCM, etc.)

*Limited/Painful AROM + PROM. *Neuro: Check Motor/Sensory/Vascular fxn distally *X-RayReveals fracture line of the clavicle. *CT/MRI - Surrounding neurovascular damage and soft tissue inflammation *Tuning Fork -

Osteolysis of distal clavicle

Superior Nontraumatic/Overuse

*Weight Lifter *Benches over 300lbs , clean jerk, or dip. *Secondary to AC seperation *Exhashebated by Activity.

*Distal clavicle dull ache. *NAD * Possible palpable loss of clavicular contour (due to resoprtion)

*Pain @ ABd > 90 . *Full ROM - Crepitus over AC Joint.

*X-ray or Bone Scan- resorption of A/C joint space and clavicle..

Anterior Dislocation

Anterior Traumatic

*Abd + Ext. + Ex Rot. Nontraumatic cause

*Possible

*Flat Deltoid *Promiinent Anterior Humeral Head *Prominent AC w/Post. Depression * Pt holds arm in ABd + Ext Rot.

*Palpable Humeral Head Anteriorly Displacement ( not in GH joint space)

*Surrounding Tissue *Any ROM elicits Pain and Edema/Swelling. apprehension, hence limited. * Rotator Cuff muscles palp with be painful and spastic. *Possible Paralysis of deltoid muscle and teres minor if axillary n. has been damaged.

* Dugas * Ant Apprehension *X-Ray: Anterior Translation of Humeral Head Anteriorly , empty glenoid, and Hill Sach Fracture found w/ reccurent dislocation. Neuro: Possible diminshed Motor/Sensory/Vascular fxn distally (axillary n, brachial artery, etc.)

Labrum Tear

Anterior Traumatic or Nontraumatic/Overuse

"Popping, Catching, Snapping." Followed by Deep Vague Ache Traumatic: Falling on forward flexed arm. Sharp biceps tendon pull on labrum. Nontraumatic: Overhead activities(bench press/overhead pressing) or golf club strike on ground.

* A ROM - Painful "sticking" movement releived by repositioning and a "clunk". *P ROM - crepitus and painful endpoint.

*Clunk *Obriens *Anterior Drawers * Xray: Glenoid Bony Involvement *CT Arthrogram: Labral tear (SLAP, Bankart, etc.) and degree.

Subscapularis Tendonitis

Anterior Traumatic or NonTraumatic/Overuse

Nontramatic: Pain back of arm, under shoulder blade. Traumatic: Inflammation of subscap tendon, subscap strain ( ex. Rot stretch, or overuse w/ int. Rot), Ant. Instability, or overhead activities.

PT: *Lesser Tubercle of humerus.

Point tenderness @subscap tendon. * Decreased Internal A ROM Localized swelling (more severe * Normal P ROM cases) Spongy feel to palpation (more severe cases)

*Lift Off (increased pain @LT) *Belly Press *Lag *Inferior Apley's Scratch *Arthrogram CT - reveal inflammation of tendon.

Acute Calcific SubAcro Bursitis

Anterior Traumatic or NonTraumatic/Overuse

Pt. presents w/ severe shoulder pain * Supportive Nature/ Guard w/any shoulder movement, either Avoid ROM insidious onset or subsequent to a fall or *Edema/Swelling other major trauma.

*TP @ Ant/Inf Acromion

*TS bursa @ sub bursa

*Painful A/P ROM especially ABduction + Flexion w/ Sharp Pain.

*Push Button *Dawbarns *Xray

Supraspinatus Tendonitis

Anterior NonTruamatic/Overuse

Anterior Shoulder Pain due to trauma, athletes pitching or bowling, continuous overhead activity, or lifting overhead. Nontraumatic

*Greater Tubercle

Point tenderness @ supraspinatus tendon Localized swelling (more severe cases) Spongy feel to palpation (more severe cases) *Pain

*A$$ kick sign *Difficulty Empty Can with first 15 degrees of ABduction Hornblowers Apleys Superior Scrath Test. Jobes Codman's arm drop

O.A. of the AC Joint??????

Anterior Nontraumatic/Overuse

Post-Traumatic or Post-Infection.- Years Guarding after AC seperation Overhead heavy weight lifting - especially with young weight lifter.

*Joint Effusion *Tenderness

Cross Chest Test AC Compression

Subdeltoid Bursitis

Antero - Lateral Nontraumatic/Overuse

Antero- Lateral Shoulder Pain, awaken *Edema at night due to sleeping on side of lesion, acute pain superimposed on Hx of chronic milder pain. Often associated w/ impingment syndrome

*Tenderness along lateral acromion.

Subdeltoid, Subacromial Bursa Pain Limited Active ABduction, *Push Button + Tenderness + Edema especially end range flexion, may *Dawbarns increase with passive movement. *Arthrogram *Ultrasound *MRI

Biciptial Tendonitis

Anterior Nontraumatic/Overuse

Inflammation of long tendon & tendon Pos guarding (especially with sheath of biceps brachii. Overhead gait) sports, impingment/overuse, "popping in Loss of tandem swing. groove" or ab/ext Rot .

Bicipital Groove for tenderness and pain.

Point tenderness @bicipital tendon Localized swelling Spongy feel to palpation

Decrease AROM and Painful PROM. Mainly w/flexion, abduction, and Ex. Rot

Speeds Yeargason Abbot Saunders Obriens (2nd part) Ludington's Transverse Humeral Ligament

Traumatic Instab

Anterior/Lateral/Posterior Traumatic

Ant: Overstretching into Abduction/External Rotation, History of Shoulder Dislocation, Most Common, Fall to posterior of shoulder. Post: Fall on ant. Shoulder. Inf: Fall on sup. Shoulder.

Possible guarding of Affected arm. Sulcus Sign may be present

Humerus

*Acute- Local tendernes + myospasm + MFTP's - Deltoid and R.C mm's. *Anterior Rotator Cuff Tendons - Possible swelling

Limited AROM (esp supination and Abduction) Painful PROM

Orthos: Ant: Anterior App Test + Relocation Test + Anterior Drawers + Multidirectional Instability + Dugas Inf.: Sulcus test + Faegans Post: Posterior Apprehension+ Posterior Drawer's + Jerk Test Xray - Subluxed Humerus or Fractures CT Arthrogram- Comcommitant labral tears.

Nontraumatic Instability

Anterior/Lateral/Posterior Nontraumatic/Overuse

Usually Asymptomatic until Sudden Possible guarding of Affected traction of arm results in Pain + arm. Sulcus Sign may be Weakness of entire arm (subluxation). present OR Hx of Overhead activity overuse that resulst in sense of Fatigue.

None

Tender/Painful/Hypertonic compensatory MM/Tendons (rhomboids,pec major, traps). Mutidirectional lax ligs.

Decreased A/P ROM (sometimes Orthos: norm PROM w/ pain) Ant: Anterior App Test + Relocation Test + Anterior Drawers + Multidirectional Instability + Dugas Inf.: Sulcus test + Faegans Post: Posterior Apprehension+ Posterior Drawer's + Jerk Test Xray - Subluxed Humerus

Impingement Syndrome Primary > 35yoa Secondary <35yoa

Anterior/Lateral/Posterior Nontraumatic/Overuse

Early General Shoulder ache Pain Possible guarding of Affected with overhead activity. Hx of arm. Pos Swelling. Poor shoulder dislocation. Difficulties Sleeping Posture. on Affected Side w/Primary (not Secondary) PROGRESSIVE!!!!!!!! Posterior Impingement - posterior pain (dead arm - but no true neuro deficits)

Subacromial: Pain @ under AC joint, and @ greater tubercle Infra/teres m: Posterior tenderness Subcoracoid: Pain @ corocoid process

Subacromial: Pain @ Pain Arc ROM 70-110. Possible Supraspinatus Tendon, Bicipital "Catch" sensation. Tendon, & Bursa. Infra/teres m: Posterior tenderness Subcoracoid: Impinged and painful subscapularis tendon

Wallet Sign Neers Relocation Test Hawkins Xray Osteophytes under acromion + acromion abnormalities. Lidocaine Inj into bursa- diff b/w tendo and bursa.

Goes hand in hand w/instability 9dependat on age for primary or secondary cond.0 and rotator cuff injury.

Supraspinatus Sprain/Strain

Posterior Traumatic

Possible Assymetry and/or swelling over Supraspinatus

Greater Tubercle of Supraspinatus Muscle for Humerus, Scapular Spine, pain,tenderness, spasms, MFTPs. Supraspinous Fossa area will elecit pain and tenderness.

Decreased ABduction + External Codman's Rotation + Pain A ROM + No Jobes Pain P ROM Hornblower Empty Can Aplay's Superior Scratch Supraspinatus Muscle Test and Stretch (reveal increased pain/weakness)

Subscapularis Sprain/Strain

Posterior Truamatic

Hyperextension or external Rotation trauma

Possible arm guarding and swelling.

Lesser Tubericle, Lateral/Superior Aspect of Scapula.

Subscap tendon to posterior arm pit Decreased Internal Rotation + to attempt irritation subscap muscle. Pain A ROM + NO Pain P ROM

Belly Press Lift off (weakness @LT) Lag Sign Apley's inferior Scratch Subscapularis Muscle Test and Stretch (revelas increased pain/weakness) Rule Out Other SITS Muscls Teres Minor Muscle/Motor Test Infraspinatus Muscle Test and Stretch (reveal increased pain/weakness)

Infraspinatus or Teres Posterior Traumatic Minor Sprain/ Strain

Possible Swelling over either

Greater Tubericle of Humerus and infraspinus fossa of the scapula.

Infraspinatus Musculotendinous junction, Teres Minor Musculotendinous junction.

Decreased External Rotation + Pain A ROM + NO Pain P ROM

Posterior Dislocation

Posterior Traumatic

Severe: Int. Rotation + ADduction Direct Ant. Blow (shoulder) Fall on outstretched Hand

*Arm held Adduction + Int. Rotation *Flat Anterior Shoulder *Prominent Coracoid *Swelling

Humeral Head is palpable under posterior acromion process.

*Hypertonicity/Stretched Anterior MM Surrounding tissue edema.

Limited Ext. Rot + ABduction + Supinated Flexion ROM.

Posterior App Test Posterior Drawers Jerk Test XRay Neuro: Check Motor/Sensory/Vascular fxn distally

Infraspinatus Tendonitis

Posterior Nontraumatic/Overuse

Nontramatic, Pain to sustained exertion. Possible gaurding to external rotation, atrophy of infraspinatus.

Greater Tuberosity of Humerus

Point tenderness @infraspinatus tendon Localized swelling (more severe cases) Spongy feel to palpation (more severe cases)

Limited ROM of external rotation. Infraspinatus Muscle Testing Ultrasonography of greater tuberosity.

Othor - Is it muscle testing???????

Little Leaguers Shoulder

Posterior Nontraumatic/Overuse

Young baseball pitchers - due to practicing curve balls. Rotational stresses on growth plate. Gradual pain @ the proximal humerous

Guarding of affected arm. Assymetrical SITS muscle mass bilaterally.

Pain and Tender Proximal Humerus (specifically lateral humerus).

Overdeveloped/hypertonicity internal Increase External A/P ROM Rotators. Weak External Rotators. Anterior Capsule laxity.

External Rotation Muscle (SS/IS/TMTest ) Empty Can Test. X-ray (widening of proximal humeral epiphysis, sclerotic fractures, and fragmentation). Bilateral view and AP internal and external views

Hypermob. Of G.H. Joint

Truamatic or NonTruamatic

Ligament laxity, mm inbalances, or joint No significant visual Findings malformatiuon. Traumatic: young children - decreased proprio, and nerve injury. Atraumatic: Congenital looseness of GH ligamnet ( double-jointed). Aquired: Repeated overhead activities *Ant, Pos, Mulit*

Proximal Humerus

Local myospasms and MFTP's of SITS tendons, weakness causing instability

Excessive ROM in all arcs.

Ant: (+) Ant. App, Ant drawers, and Relocation. Post: (+) Post Drawers, and Post. App. Inf: (+) Sulcus test, faegins @ 80-90 degrees

Rotator Cuff Tear

Traumatic Or NonTraumatic

Traumatic: Excessive force from trying to lift heavy object, catch heavy object, or force to top of shoulder. Nontraumatic: Degeneration w/overhead activites. Most commonly supraspinatus. Vague spain in shoulder area, catching sensation, Pts cant sleep on affected side.

Posible Guarding, Pain and Weakness of Affected Arm. Catching sensation. Unable to lift arm with complete tear. Assymetrical contour of SITS muscle mass bilaterally (muscle bunching w/ movment). Possible displacement of humerus due to loss of dynamic instability.

Greater and Lesser Tubercles of Humerus. Acromion process (pain, tenderness)

SITS Tendons insertions (may reveal lack of tendon insertion and pain/tenderness/swelling/possible ecchymosis)

Partial: painful but Normal AROM. N PROM Larger: weakness + decreased AROM . N PROM Complete: Complete loss of AROM + N PROM.

SS: (+) Empty Can, Codman's Arm Drop, Full Can, Aply's, Hornblowers, and Jobes. SC: (+) Lift off, Lag sign, Aply's inf, & Belly Press. IS/TM: Muscle Test XRay Humeral Head Ultrasound or MRI - confirm the location and extent of a tear.

Adhesive Capsulitis

NonTraumatic

Pt over 40yo. 70% female 40 to 60 (postmenopausal women). Insidious onset, Post Injury or Operation., Pain lasting few weeks, followed by gradual stiffening. Pain moderate to severe. Interferes with sleep.

Possible unilateral loss of tandem swing. Possible Atrophy of scapular and deltoid muscles. Shoulder Shrugging/Assymetry.

Hypertonic GH ligs.

Decreased to Completely Limited AROM and PROM. Intense Pain at ROM endrange of GH. Excessive scapular ROM.

Xray - demonstrate a decreased joint cavitiy. Ultrasound - fibrous synovial adhesions. MRI - If condition does not improve with conservative care to rule out other rotator cuff disease.

O.A. of G.H. Joint

Nontrauamtic (w/HX of Truama)

*Chronic degenerative* Uncommon and Possible guarding of affect 2ndary to other disorders, Hx of trauma shoulder and overuse, Older men (R.A. for Women)

Possible palpation of bone Tenderness and trigger pts in mm's spurs of the shoulder, upper back, and neck

Limited ROM of anterior flexion

X-Ray - decreased and other signs DJD at GH joint space. CT scan or MR -I for bony remodeling

TOS

worse with driving, lifting, carrying, writing, overhead activites, hard to grip/hold, cold and heavy arms.

Visible Scars over clavicle. Painful Clavicle and Poor Posture. Obesity. Neuro Humerus. symptoms in distal extremity. Pallor/Cyanotic of distal extremity. Slouched Shoulders.

*Scar tissue of supraclvaicular area. NAD *Hypertonic Scalene Muscles. *Paresthesia of distal extremity. * Pain along the inside of the arm and ocaasionally 4/5th phalanges.

Allen's Maneuver and Test Adson's Halsteads Costoclavicular Hyperabduction Xray - for possible cervical rib. CT/MRI - If severe neurovascualr involvement.

Rotator Cuff tear, Glenoid Labrum tear, Posterior Fall On Dislocation, Clavicular Outstretched Hand Fracture AC Seperation Arm Forced Into Anterior Dislocation, Anterior Abduction/External Musculature Strain, Fracture Rotation Blow to Shoulder Area Fall Onto TOP of shoulder Traction Injury to Arm AC Seperation, Disclocation Shoulder Pointer, AC seperation, Distal Clavicle Fracture. Plexus injury, Medical Subluxation.