CHI456 Lecture Notes II PDF

Preview

Summary

CHI456 Differential DiagnosisLecture 6 Shoulder & Arm PainShoulder PainRed Flags Shoulder Pain - Fever (septic arthritis, osteomyelitis) - Constitutional symptoms - Skin redness, swelling and warmth of the shoulder area - History of trauma (dislocation, fracture, rotator cuff tear) - History...

Description

CHI456 Differential Diagnosis Lecture 6 Shoulder & Arm Pain Shoulder Pain Red Flags - Fever (septic arthritis, osteomyelitis) - Constitutional symptoms - Skin redness, swelling and warmth of the shoulder area - History of trauma (dislocation, fracture, rotator cuff tear) - History of inflammatory arthritis - History of cancer - Motor or sensory loss in arm Special concerns with shoulder pain - Unremitting pain not associated with direct movement of the shoulder - Severe, sharp stabbing pain of several minutes duration Traumatic and Overuse Injuries - Blow to the anterior shoulder - Fall onto top of shoulder - Fall on an outstretched arm - Arm forced into external rotation - Sudden traction to the arm - Sudden pain with weightlifting

Shoulder Pain - Referred pain/cervical spine - Referred pain/visceral - Radicular pain - Brachial plexus entrapments - Local causes of pain o Trauma o Overuse o Arthritis

Evaluation - Pain localization o Anterior o Lateral o Superior o Posterior - Age and onset - Pediatric/childhood onset - Middle-aged onset - Weakness - Restricted motion - Snapping - Groin pain - Thigh complaints Key Points History - Patients age: can give strong indication to type of pathology present (think tendinopathy) - Psychosocial Hx: sport or occupation (impression of repetitive loading) o Frequency (or recent changes) o Duration o Nature - Onset o Insidious: frozen shoulder, arthropathy (ACJ or GHJ), Sub Acromial Pain Syndrome (SAPS), atraumatic instability o Traumatic: RC tear, labral, dislocation, sprain, fracture. o Secondary to immobilisation

Restrictions in Range of Motion - Acute bursitis - Adhesive capsulitis - History of trauma - Pain in midrange of abduction - Contractile lesion - Restriction in both active and passive - Pain felt at a discrete point with active ROM

Physical Examination - Observation o Scapula (resting position, winging) o Muscle bulk o GH (anterior, sulcus sign, step deformity) o Asymmetry in shoulder contour  Changes on affected side  Associated with a loss of rotation - ROM: guided by subjective information (Hx) o Painful arc o End ROM pain o PROM>AROM, with AROM pain limited o PROM=AROM, with End ROM pain - Motion palpation - Palpation

-

Pain behaviour o With shoulder movement (repetition) or position (overhead) o Pain at rest: inflammatory, mechanical? Probable Dx - Cervical spine referral - SAPS (Sub Acromial Pain Syndrome) o Rotator cuff tendinopathy, SA bursitis, RC tear, tendinosis - Adhesive capsulitis - Labral lesions – SLAP, non-SLAP - Biceps tendinopathy

Pitfalls Consider these if patient not responding and serious conditions have already been ruled out: - PMR - OA of AC joint - Gout/pseudogout (rare) - Winged scapula (muscular fatigue pain) - Misdiagnosing posterior dislocation of the shoulder joint - Misdiagnosing recurrent subluxation of the shoulder joint - Misdiagnosing rotator cuff tear or degeneration - Overlooking an avascular humeral head (post fracture) Common Shoulder Conditions by Age

Diagnosis Tips - Differential diagnosis for the shoulder pain is difficult - Any person >65 years of age presenting with shoulder pain and/or dysfunction needs to be screened for viscerogenic origin o The shoulder is a common site for visceral referral

Viscerogenic

-

Impingement tests

Serious disorders: to be ruled out - Cardiovascular referral o Myocardial infarction, angina - Neoplasia o Pancoast tumour, primary or secondary in humerus - Severe infections o Septic arthritis, osteomyelitis - Rheumatoid arthritis - Axillary vein thrombosis Masquerades - Spinal dysfunction - Depression - Diabetes Mellitus (DM): increased risk of adhesive capsulitis - Drugs: e.g. corticosteroids could lead to AVN of humeral head, anabolic steroids can result in osteolysis of the ACJ

Viscerogenic Look for shoulder pain accompanied by any of the following: - Pleuritic component - Exacerbation by recumbency - Recent history of laparoscopic procedure (risk factor) - Coincident diaphoresis (cardiac) - Exacerbation by exertion unrelated to shoulder movement (cardiac) - Associated GI signs and symptoms - Associated urologic/gynaecologic signs and symptoms Take a comprehensive RoS History

Kehr’s Sign Is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. - Referred causes where the pain is unchanged by shoulder movement o Perforated ulcer o Intraperitoneal bleeding (e.g. ruptured spleen) o Post-surgery/laparoscopy o Ectopic pregnancy Non-Traumatic Causes of Shoulder Pain

Subacromial Pain Syndrome (SAPS) Is defined as all non-traumatic, usually unilateral, shoulder problems that cause pain, localized around the acromion, often worsening during or subsequent to lifting of the arm. Bursitis, tendinosis, supraspinatus tendinopathy, partial tear of the rotator cuff, biceps tendinitis, or tendon cuff degeneration are all part of SAPS. (Diercks 2014) Clinical Presentation - Anterior lateral pain, with potential referral to deltoid insertion o Suggests SA structures involved - Pain behaviour o Overhead activities o IR in positions of elevation - Physical Exam: o Acromial margins or SA space tenderness o Painful arc during active shoulder elevation (abd>flex)  ± End ROM pain o Worse with humerus IR o Orthopaedic tests...

This label does suggest: - A benign condition - Presence of a mechanical disorder o (i.e. symptoms are influenced by movement/load) - Dx is still based on comprehensive clinical examination - Chiropractic Tx is indicated and the condition will respond favourably Investigations - Ultrasound is likely an accurate method for the detection or exclusion of rotator cuff tendinopathy, subacromial bursitis, biceps tendon rupture, and calcific tendinosis (Ottenheijm et al 2010) - Advised as the most cost-effective and valuable diagnostic imaging if non-operative treatment fails - May be combined with conventional radiography to determine extent of osteoarthritis, osseous abnormality or presence of calcium deposits

Some tests have amazing sensitivity (good at reproducing symptoms), others excellent specificity - Hawkins-Kennedy test, the painful arc, and infraspinatus muscle test o Diercks et al 2014. Guideline for diagnosis and treatment of subacromial pain syndrome - Hawkins-Kennedy test, Neer’s, painful arc, empty can and infraspinatus muscle test - >3/5 provides: Sensitivity (0.75), Specificity (0.74) (Michener et al 2009) Management - This diagnosis guides the Chiropractor as to whether - Mobilisations their intervention is warranted - STT - On its own it does not provide enough information to - Motor control retraining (particular scapula) direct management - Specific strengthening, endurance and proprioceptive - Therefore, management should be based on: training o Dominant deficit: o “A specific, progressive exercise program  Movement impairment? Motor focusing on training the rotator cuff and control? Postural loading? scapular stabilisers was effective in improving o Intrinsic and Extrinsic factors contributing function, reducing pain and reducing the need of surgery for patients with chronic o Stage subacromial impingement syndrome.” o Patients activities and participation Holmgren A et al (2012) restrictions - Related home exercise and management o Goals and preferences of the patient - EPA (pain and inflammation management) o Take into account presence of underlying pathology (i.e. tendinopathy if confirmed via US). Impingement Syndrome Narrowing of the space btw acromion and humerus, Neer’s stages: - Type I: 40 years old, Small Rotator Cuff Tear, Subacromial Decompression with Debridement/Repair - Type IV: >40 years old, Large Rotator Cuff Tear, Sub Acromial Decompression with Repair Clinical Sign Types of impingement - External - Contemporary thoughts are the impingement is o Primary considered a clinical sign, rather than a diagnosis o Secondary - Can occur without signs of RC pathology - RC pathology rarely will exist without impingement - Internal signs Rotator Cuff Tendinopathy Management Categories Reactive Tendinopathy (inactive person suddenly doing a lot of Rehab shoulder loading activities with inadequate rest and nutrients – - Deloading & reloading (gradually) of tendon body can’t keep up with level of repair) - Address underlying impairment - Load reduction - Address contributing factors (extrinsic and intrinsic) - Reduce swelling o Mal-adaptive scapula mechanics o Ice, ibuprofen (short term) o Suboptimal HH control - Slow reloading o Training errors (technique) Tendon Disrepair - Load reduction - Reduce swelling - Graduated reloading Degenerative Tendon - Relative rest / unloading for pain control - Graduated tendon reloading Traumatic GH Instability History Physical Examination - General shoulder pain Weakness of local muscles (i.e. RC)

Worse with activity or when the arm is placed in either an overhead position or carrying at side or apprehension position (90 degrees flx/abd and ER) o Better with rest and heat Past history of shoulder dislocations Often associated with impingement symptoms o

-

Atraumatic GH Instability (AMBRI) aka MDI Clinical Presentation - Young M) - Bilateral, multidirectional - Gradual onset of pain related to sport - Good ROM – excessive (hypermobile) - +ve impingement signs - +ve instability tests o Sulcus sign, AP, PA drawer tests o Apprehension and relocation tests Long Head of Biceps Pathology Clinical Presentation - Anterior shoulder pain in bicipital groove - Can be difficult to distinguish from associated pathology especially RC - Pain on speeds test – questionable specificity Investigations?? GHJ OA History - Vague, diffuse shoulder pain - Insidious onset, slowly progressive - Present at rest AND exacerbated by movement or activity - History of manual labour Adhesive Capsulitis (Frozen Shoulder) What is it? Defined as a “global limitation of glenohumeral motion resulting from contracture & loss of compliance of the glenohumeral joint capsule”. (Vad et al. 2000) - Pain & GHJ motion restriction due to synovial inflammation with subsequent capsulitis & reactive capsular fibrosis - From unknown cause (idiopathic) - Common at the age of over 40 - FS has an incidence of 3–5% in the general population, and is a common shoulder disorder in orthopaedic practice (Bron, de Gast and Franssen 2011)

Clinical Features - F>M (2:1) - Tends to be more prevalent in diabetic population - Gradual increase in pain following by loss of ROM - Idiopathic but could give Hx of GHJ trauma or prolonged immobility o Surgery or mild trauma Management Questionable effect of conservative management on natural history Phase 1 - Pain relief – modalities, activity mod, positioning - Avoid aggressive mobilisation/manipulation

-

Instability tests Increased ROM + accessory movements Altered end feel Apprehension Normal neurovascular screen (rule out axillary nerve damage) Investigations - MRArthrography or arthroscopy are ideal to diagnose a bankart lesion Management - Assess the rotator cuff muscles - Ensure correct biomechanics - Adequate strength o May require progressive training of scapula and RC muscles - Activity modification - Assess the kinematic chain

Management - Address impairments that are contributing to the disorder - As SAPS rehabilitation

Physical Examination - Painful, restricted global loss of motion - Crepitus Investigations - Joint space narrowing - Marginal osteophytes - Glenoid erosions Pathogenesis Painful stage: Inflammatory (synovitis and capsulitis) - Commonly gradual onset of moderate to severe shoulder pain which limits and restricts movement in all planes - Capsule is swollen and oedematous - No loss of strength or stability Frozen stage: GH capsule contracted and fibrosed - Pathology has resolved - Capsule is now contracted - Relatively pain-free restriction of movement in every direction - Reduced shoulder function Thawing stage: Recovery - Stiffness has begun to ease - Graded return of ROM and function - Could take up to 2 years Physical Examination - AROM and PROM are both lost - Capsular pattern of restriction o ER>Abd>IR>Flex - Pain at EROM rather than mid-range - Secondary impingement could be a consequence - Negative isometric tests Phase 2 -

Minimise loss of ROM Use heat to assist rehab Use of passive movements initially (PFROM) Trial soft tissue techniques

Phase 3 -

Potential to make the disorder worse at this stage Advice and education Avoid mal-adaptive postural changes Aim to regain ROM Encourage gradual resumption of Function Don’t attempt to fix scapula dysfunction yet

Phase 4 - Encourage and promote natural history - Increase ROM - Address secondary impairment o UL weakness, scapula dysfunction etc.

Prognosis for MSK Shoulder Pain - High Functional Disability at baseline was considered a negative prognostic indicator - Long duration of symptoms was considered a negative prognostic indicator - Several studies associated age with poor function, though several showed no relationship (Chester et al 2013)

Arm & Hand Pain Key Points History - Patients age: can give strong indication to type of pathology (e.g. OA) - Psychosocial Hx: sport or occupation (impression of repetitive loading, tendinopathy) o Frequency (or recent change in) o Duration o Nature - What impact is it having on functions, ADL, work, sport (relevant outcome measures – DASH, SPADI) - Location o Localised pain over lateral epicondyle: Lateral epicondylitis o Localised over common flexor origin: medial epicondylitis o Localised anterior elbow pain: distal biceps tendinopathy o Localised pain at tip of triceps insertion: distal triceps tendinopathy o Olecranon bursa: bursitis? - Relationship to other symptoms o Paraesthesia, neck or shoulder complaints - Onset o Insidious: OA, lateral epicondylitis, De Quervain’s, CTS o Traumatic: dislocation, sprain, fracture - Pain behaviour o With repetitive movement or sustained position (occupation or sport) o Pain at rest or night - Clarify complaint o Pain, stiffness, crepitus - Clarify mechanism, if traumatic o Fallen on outstretched hand o Fallen on tip of elbow o Hyperextension of elbow o Stretch to inside of elbow o Sudden traction Physical - Observation o Posture - ROM: guided by subjective information o Active and passive o Passive accessory (motion palpation) - Palpation o Tenderness elicited o Crepitus or mechanical clicks - Muscle strength o Isometric (grip), MMT, endurance (repetition) - Muscle length - Sensation o Especially if neurological signs associated, or suspicious of cervical spine involvement - Orthopaedics - Screening o Cervical, shoulder, thoracic, cardiac Probable Dx Serious disorders: to be ruled - Cervical spine referral (dysfunction of the lower - Cardiovascular referral cervical spine) o Myocardial infarction, angina, axillary vein

-

Disorder of the shoulder referring distally Medial or lateral epicondylitis Overuse tendinopathies CTS OA: thumb & DIP joints

Pitfalls Things to consider if patient not responding and serious conditions have already been ruled out - Entrapment neuropathies or peripheral neuropathy (e.g. median or ulnar nerve) - Pulled elbow (specially in children)

thrombosis Neoplasia o Pancoast tumour, primary or secondary bone tumours - Severe infections o Septic arthritis, osteomyelitis, infections of tendon sheath or fascial spaces Masquerades - Spinal dysfunction - Depression - Diabetes – polyneuropathy (gloves/stocking distribution) -

Elbow/Forearm Pain Special concerns with elbow pain - Decreased pulses - Marked swelling and paraesthesia - Recent changes in elbow - Skin breakdown or wound problems - Warmth and swelling associated with a fever

Conditions to know very well - Epicondylitis - Cervical radiculopathy - Entrapment and peripheral neuropathies - Sprains/strains - Fractures - Rheumatoid arthritis - Osteoarthritis - Pulled elbow - Compartment Syndrome - Osteochondritis dessicans - Olecranon bursitis

Diagnosis Tips - Fractures can easily be misdiagnosed - Overuse injuries are common in the elbow - Tendinopathy refers to both o Tendinitis – acute inflammatory process characterised by the presence of inflammatory cells o Tendinosis – a degenerative process resulting in incomplete/failed tendon healing characterised by disorganised collagen fibres - Treatment of overuse injuries at the elbow needs to address proximal areas of weakness and decreased flexibility to restore alignment and improve biomechanics at the elbow - Treating just the elbow will o Lead to less than optimal outcomes o Not assist in preventing the recurrence of the injury and chronic tendon symptoms Lateral Epicondylitis Clinical Presentation Management - Pain and point tenderness over the lateral epicondyle - Activity modification (rest from offending activity) (common extensor origin) - RICE & NSAIDs in acute phase - Pain can refer to the wrist and hand - Manipulative therapy - Reproduced by: - Therapeutic exercise program o Gripping or manual tasks that require - Taping techniques (offloading) (McConnell 2000) manipulation of the hand - Myofascial release - Sustained Lateral Glide with Pain Free Grip o Resisted wrist extension and passive wrist (Vincenzino 2003) https://youtu.be/aEzBL5t2h3s flexion (lateral epicondyle) - Grip force is reduced when compared to the other arm - Common amongst amateur tennis and squash players, repetitive manual tasks (Carpenter, bricklayer, housewife, gardener, dentist, violinist) - Course: 6 to 24 months - Outcome measures o PFGS Cervical Radiculopathy

-

Pain is increased with cervical movement and use of extremity Coughing or sneezing may increase symptoms 90% probability of CR if 4/4 tests are positive (65% if 3/4) (Wainner, Spine 2003) o Cervical rotation flexion>abduction>extension This gives one of the strongest indicators that the issue is intra- articular in nature - True hip joint pain is felt deep within the buttock or anteriorly in the groin and sometimes it refers to the anterior thigh - True hip joint pain will be present with active and passive ROM loss and increases with weight-bearing o Standing, walking, running, steps - Pain on the lateral side or posterior aspect of the hip is usually not caused by an intra-articular problem but more likely results from a trigger point, bursitis, knee, SI, or back problem - Be very cautious of hip pain presenting in children Causes of Buttock Pain -

-

and rapid change of direction Labral tears of the acetabulum can also cause groin pain

Thigh Pain - Entrapment of the lateral femoral cutaneous nerve, meralgia paresthetica, needs to be considered - Lateral pain is often associated with ITB syndrome - Greater trochanteric bursitis is also a common cause of lateral hip pain and is often caused by a tight ITB

Causes for Hip Pain

Articular & Muscular Control of the Hip Three components working together: - Bony structures - Passive joint structures (labrum, joint capsule, ligaments) - Hip musculature Bony Morphology Femoroacetabular joint - Synovial joint formed between the head of the femur and the acetabulum - Acetabulum is nestled within the pelvis, facing infero-laterally and “normally” anteverted by 26° - The femoral head is also anteverted by 10-15° o The positioning of both acetabulum and femur produce a reduced anterior bony stability

Passive Joint Structures Acetabular labrum - Around the rim of acetabulum - Maintains joint fluid pressure - Deepens the joint and absorbs forces - Thinnest and most vulnerable anteriorly Ligaments - Transverse Acetabular ligament - Ligamentum Teres - Iliofemoral ligament Femoroacetabular Impingement Clinical Presentation - Gradual onset of hip/groin pain

Hip Musculature Stabilisers’ function - Locate head of femur - Minimise stress on labrum and rim

Examination - Reduced ± painful ROM

-

Progressive in...