Podcast
Questions and Answers
What is the most common direction of glenohumeral dislocations?
What is the most common direction of glenohumeral dislocations?
- Inferior
- Posterior
- Superior
- Anterior (correct)
What physical examination finding is most suggestive of anterior shoulder dislocation?
What physical examination finding is most suggestive of anterior shoulder dislocation?
- Absence of pain
- Full range of motion
- Arm held in internal rotation
- Arm held in external rotation (correct)
Which of the following is LEAST likely to be associated with a focused history for shoulder dislocation?
Which of the following is LEAST likely to be associated with a focused history for shoulder dislocation?
- History of injury/prior dislocation
- Hand dominance
- History of throwing or racket sports
- Family history of dislocations (correct)
In the context of shoulder injuries, what is a key differentiator of shoulder subluxation from a complete dislocation?
In the context of shoulder injuries, what is a key differentiator of shoulder subluxation from a complete dislocation?
Which of the following interventions is CONTRAINDICATED in the acute management of a shoulder dislocation?
Which of the following interventions is CONTRAINDICATED in the acute management of a shoulder dislocation?
After a shoulder dislocation, a patient should typically use a sling for how long?
After a shoulder dislocation, a patient should typically use a sling for how long?
What is the primary distinction between adhesive capsulitis and rotator cuff pathology?
What is the primary distinction between adhesive capsulitis and rotator cuff pathology?
What is a key characteristic of adhesive capsulitis (frozen shoulder)?
What is a key characteristic of adhesive capsulitis (frozen shoulder)?
Which of the following conditions is MOST likely to be associated with an insidious onset?
Which of the following conditions is MOST likely to be associated with an insidious onset?
During a physical exam for suspected adhesive capsulitis, which finding is most indicative of the condition?
During a physical exam for suspected adhesive capsulitis, which finding is most indicative of the condition?
A patient presents with limited range of motion and pain that is worse after activity, but passive range of motion is normal. Which condition is most likely?
A patient presents with limited range of motion and pain that is worse after activity, but passive range of motion is normal. Which condition is most likely?
What is the MOST appropriate initial management strategy for adhesive capsulitis?
What is the MOST appropriate initial management strategy for adhesive capsulitis?
Which of the following is a "Blue Directive" action for management of adhesive capsulitis?
Which of the following is a "Blue Directive" action for management of adhesive capsulitis?
What is the most common cause of injury to the brachial plexus?
What is the most common cause of injury to the brachial plexus?
A patient with a suspected brachial plexus injury reports pain and neurological symptoms that do not follow a typical dermatomal pattern. What does this suggest?
A patient with a suspected brachial plexus injury reports pain and neurological symptoms that do not follow a typical dermatomal pattern. What does this suggest?
Which of the following mechanisms is MOST likely to cause a brachial plexus injury?
Which of the following mechanisms is MOST likely to cause a brachial plexus injury?
Which finding on physical exam would strongly suggest a brachial plexus injury?
Which finding on physical exam would strongly suggest a brachial plexus injury?
A patient presents with suspected brachial plexus injury. Pain radiates to the neck and shoulder, but there is sensation loss to the thumb and index finger only. What other condition must be differentially considered?
A patient presents with suspected brachial plexus injury. Pain radiates to the neck and shoulder, but there is sensation loss to the thumb and index finger only. What other condition must be differentially considered?
What statement is MOST helpful to a patient with a brachial plexus injury?
What statement is MOST helpful to a patient with a brachial plexus injury?
Which of the following statements is MOST accurate regarding biceps tendon ruptures?
Which of the following statements is MOST accurate regarding biceps tendon ruptures?
What physical exam finding is MOST indicative of a biceps tendon rupture?
What physical exam finding is MOST indicative of a biceps tendon rupture?
In a focused history for a suspected biceps tendon rupture, which of the following is LEAST relevant?
In a focused history for a suspected biceps tendon rupture, which of the following is LEAST relevant?
What diagnostic test is MOST useful for definitively diagnosing a biceps tendon rupture?
What diagnostic test is MOST useful for definitively diagnosing a biceps tendon rupture?
Which of the following BEST differentiates a biceps tendon rupture from biceps tendinitis?
Which of the following BEST differentiates a biceps tendon rupture from biceps tendinitis?
What is the expected outcome of a distal biceps rupture?
What is the expected outcome of a distal biceps rupture?
A patient diagnosed with a biceps tendon rupture should expect to:
A patient diagnosed with a biceps tendon rupture should expect to:
Lateral epicondylitis primarily involves the:
Lateral epicondylitis primarily involves the:
Which activity is MOST likely to exacerbate pain in a patient with lateral epicondylitis?
Which activity is MOST likely to exacerbate pain in a patient with lateral epicondylitis?
What physical examination finding is MOST suggestive of epicondylitis?
What physical examination finding is MOST suggestive of epicondylitis?
Which condition should be considered in the differential diagnosis for epicondylitis?
Which condition should be considered in the differential diagnosis for epicondylitis?
What is the MOST appropriate initial treatment approach for epicondylitis?
What is the MOST appropriate initial treatment approach for epicondylitis?
What is a key difference in Lateral vs Medial epicondylitis?
What is a key difference in Lateral vs Medial epicondylitis?
After several weeks of consistent conservative management, a patient's lateral epicondylitis is not improving. What should be considered?
After several weeks of consistent conservative management, a patient's lateral epicondylitis is not improving. What should be considered?
Which intervention is LEAST likely to be beneficial for bursitis?
Which intervention is LEAST likely to be beneficial for bursitis?
Which of the situations is most suggestive of septic bursitis?
Which of the situations is most suggestive of septic bursitis?
Which of the following conditions should be ruled out in the differential diagnosis of bursitis?
Which of the following conditions should be ruled out in the differential diagnosis of bursitis?
What is the initial treatment for non-infectious bursitis?
What is the initial treatment for non-infectious bursitis?
What is the most commonly injured carpal bone?
What is the most commonly injured carpal bone?
What is the most common mechanism of injury for a scaphoid fracture?
What is the most common mechanism of injury for a scaphoid fracture?
Where would you expect tenderness when palpating and suspecting a scaphoid fracture?
Where would you expect tenderness when palpating and suspecting a scaphoid fracture?
How should a suspected scaphoid fracture be managed initially if X-rays are negative?
How should a suspected scaphoid fracture be managed initially if X-rays are negative?
In the management of a scaphoid fracture, what emphasizes the importance of adhering to follow-up appointments?
In the management of a scaphoid fracture, what emphasizes the importance of adhering to follow-up appointments?
Which carpal tunnel syndrome symptom presents with a pain and tingling in the median distributions?
Which carpal tunnel syndrome symptom presents with a pain and tingling in the median distributions?
A patient reports waking up at night with numbness and tingling in their hand. They find relief when shaking their hand. What physical exam sign are they describing?
A patient reports waking up at night with numbness and tingling in their hand. They find relief when shaking their hand. What physical exam sign are they describing?
What anatomical occurrence defines a shoulder dislocation?
What anatomical occurrence defines a shoulder dislocation?
What percentage of glenohumeral shoulder dislocations are categorized as anterior?
What percentage of glenohumeral shoulder dislocations are categorized as anterior?
Which mechanism of injury is MOST likely to cause an anterior shoulder dislocation?
Which mechanism of injury is MOST likely to cause an anterior shoulder dislocation?
Which sport is LEAST likely to be associated with long-term overuse injuries leading to glenohumeral dislocations?
Which sport is LEAST likely to be associated with long-term overuse injuries leading to glenohumeral dislocations?
What is a key sign or symptom to recognize a shoulder dislocation?
What is a key sign or symptom to recognize a shoulder dislocation?
Numbness or tingling associated with a shoulder dislocation MOST likely suggests:
Numbness or tingling associated with a shoulder dislocation MOST likely suggests:
Which element of a patient's history is LEAST relevant when evaluating a possible shoulder dislocation?
Which element of a patient's history is LEAST relevant when evaluating a possible shoulder dislocation?
During a physical examination for shoulder dislocation, what observation is MOST indicative of an anterior dislocation?
During a physical examination for shoulder dislocation, what observation is MOST indicative of an anterior dislocation?
During a physical exam for shoulder dislocation, what condition might be suspected if the arm is internally rotated?
During a physical exam for shoulder dislocation, what condition might be suspected if the arm is internally rotated?
When evaluating a shoulder dislocation, X-rays are primarily used to:
When evaluating a shoulder dislocation, X-rays are primarily used to:
When considering a diagnosis, which condition would present WITHOUT a deformity?
When considering a diagnosis, which condition would present WITHOUT a deformity?
Which is NOT a differentiator for AC joint separation vs shoulder dislocation?
Which is NOT a differentiator for AC joint separation vs shoulder dislocation?
Following a shoulder dislocation, which of the initial steps is MOST critical?
Following a shoulder dislocation, which of the initial steps is MOST critical?
After a shoulder dislocation, a sling is typically used for:
After a shoulder dislocation, a sling is typically used for:
What is an appropriate progression of treatment AFTER initial dislocation?
What is an appropriate progression of treatment AFTER initial dislocation?
After a shoulder dislocation, how long will it take for the patient to have mild reduction in ROM and possible pain?
After a shoulder dislocation, how long will it take for the patient to have mild reduction in ROM and possible pain?
Initial management strategies for adhesive capsulitis should NOT include which of the following?
Initial management strategies for adhesive capsulitis should NOT include which of the following?
What is the typical timeframe for weekly follow-up in clinic?
What is the typical timeframe for weekly follow-up in clinic?
According to 'blue directive', what is required?
According to 'blue directive', what is required?
Which demographic is MOST prone to adhesive capsulitis?
Which demographic is MOST prone to adhesive capsulitis?
Which phase of adhesive capsulitis is associated with stiffness and severe ROM loss?
Which phase of adhesive capsulitis is associated with stiffness and severe ROM loss?
Which symptom is more likely to cause progressive global stiffness?
Which symptom is more likely to cause progressive global stiffness?
What is a key characteristic of the pain associated with adhesive capsulitis?
What is a key characteristic of the pain associated with adhesive capsulitis?
In the physical examination of a patient with suspected adhesive capsulitis, what is a typical finding?
In the physical examination of a patient with suspected adhesive capsulitis, what is a typical finding?
In the differential diagnosis of adhesive capsulitis, what key sign is present in impingement syndrome?
In the differential diagnosis of adhesive capsulitis, what key sign is present in impingement syndrome?
Which of the following is NOT a treatment for adhesive capsulitis?
Which of the following is NOT a treatment for adhesive capsulitis?
What is the typical follow-up action for adhesive capsulitis?
What is the typical follow-up action for adhesive capsulitis?
What does the 'green directive' indicate?
What does the 'green directive' indicate?
Why might an injury to the brachial plexus not fit a typical symptom pattern of an individual nerve injury?
Why might an injury to the brachial plexus not fit a typical symptom pattern of an individual nerve injury?
What is the MOST likely cause of injury to the brachial plexus?
What is the MOST likely cause of injury to the brachial plexus?
Which is an atypical sign/symptom related to brachial plexus injury?
Which is an atypical sign/symptom related to brachial plexus injury?
In a focused history for brachial plexus injury, what is the most common cause?
In a focused history for brachial plexus injury, what is the most common cause?
When examining a patient, what would you expect to find with brachial plexus injury?
When examining a patient, what would you expect to find with brachial plexus injury?
What diagnosis is likely if the pain radiates to the neck and shoulder?
What diagnosis is likely if the pain radiates to the neck and shoulder?
Initial management strategies for brachial plexus injury should NOT include which of the following?
Initial management strategies for brachial plexus injury should NOT include which of the following?
What does early follow up achieve with brachial plexus injury?
What does early follow up achieve with brachial plexus injury?
Which is a true statement regarding a biceps tendon rupture?
Which is a true statement regarding a biceps tendon rupture?
Which symptom is MOST indicative of a biceps tendon rupture?
Which symptom is MOST indicative of a biceps tendon rupture?
What part of focused history is needed with biceps tendon rupture?
What part of focused history is needed with biceps tendon rupture?
What part of physical exam assesses biceps tendon rupture?
What part of physical exam assesses biceps tendon rupture?
What is a differential diagnosis in regards to biceps tendon rupture?
What is a differential diagnosis in regards to biceps tendon rupture?
Initial management strategies for bicep tendon rupture should NOT include which of the following?
Initial management strategies for bicep tendon rupture should NOT include which of the following?
Why is daily follow is required for bicep tendon rupture?
Why is daily follow is required for bicep tendon rupture?
Where does pain present with lateral epicondylitis?
Where does pain present with lateral epicondylitis?
During the physical exam, what test would be preformed with lateral epicondylitis?
During the physical exam, what test would be preformed with lateral epicondylitis?
What is similar in the management aspects of lateral and medial epicondylitis?
What is similar in the management aspects of lateral and medial epicondylitis?
In the context of shoulder dislocations, what is the glenoid fossa?
In the context of shoulder dislocations, what is the glenoid fossa?
A patient presents with their arm held slightly away from their body and rotated outwards. Which type of dislocation does this MOST likely indicate?
A patient presents with their arm held slightly away from their body and rotated outwards. Which type of dislocation does this MOST likely indicate?
What historical detail, while relevant to overall patient assessment, is LEAST critical when specifically evaluating a potential shoulder dislocation?
What historical detail, while relevant to overall patient assessment, is LEAST critical when specifically evaluating a potential shoulder dislocation?
What physical examination finding is the MOST reliable indicator of a SLAP lesion?
What physical examination finding is the MOST reliable indicator of a SLAP lesion?
If a patient is being evaluated for a shoulder dislocation and is unable to perform any range of motion (ROM) due to pain and instability, what is the MOST immediate concern?
If a patient is being evaluated for a shoulder dislocation and is unable to perform any range of motion (ROM) due to pain and instability, what is the MOST immediate concern?
After a shoulder dislocation is reduced and stabilized, what timeline is MOST appropriate for encouraging gentle range of motion exercises?
After a shoulder dislocation is reduced and stabilized, what timeline is MOST appropriate for encouraging gentle range of motion exercises?
Which of the following symptoms or findings is LEAST consistent with the typical presentation of adhesive capsulitis?
Which of the following symptoms or findings is LEAST consistent with the typical presentation of adhesive capsulitis?
During a physical exam for suspected adhesive capsulitis, a therapist notes limited range of motion in all planes, but the end-feel is mushy and pain is the primary limitation. What differential should be considered?
During a physical exam for suspected adhesive capsulitis, a therapist notes limited range of motion in all planes, but the end-feel is mushy and pain is the primary limitation. What differential should be considered?
In the management of adhesive capsulitis, what is the PRIMARY goal of initial intervention strategies?
In the management of adhesive capsulitis, what is the PRIMARY goal of initial intervention strategies?
In the context of adhesive capsulitis, what does the 'green directive' stipulate?
In the context of adhesive capsulitis, what does the 'green directive' stipulate?
Why might an injury to the brachial plexus result in a symptom pattern inconsistent with single nerve root distributions?
Why might an injury to the brachial plexus result in a symptom pattern inconsistent with single nerve root distributions?
A patient with a suspected brachial plexus injury reports pain and neurological symptoms in a stocking-glove distribution in the affected hand. What competing diagnosis should be strongly considered?
A patient with a suspected brachial plexus injury reports pain and neurological symptoms in a stocking-glove distribution in the affected hand. What competing diagnosis should be strongly considered?
When obtaining a focused history for a suspected brachial plexus injury, which of the following is the MOST relevant?
When obtaining a focused history for a suspected brachial plexus injury, which of the following is the MOST relevant?
During a physical examination for a suspected brachial plexus injury, what finding would raise concern for a more severe injury?
During a physical examination for a suspected brachial plexus injury, what finding would raise concern for a more severe injury?
What key historical detail helps differentiate biceps tendon rupture from biceps tendinitis?
What key historical detail helps differentiate biceps tendon rupture from biceps tendinitis?
What physical exam finding BEST differentiates a distal biceps tendon rupture from a strain?
What physical exam finding BEST differentiates a distal biceps tendon rupture from a strain?
A patient with a biceps tendon rupture is likely to experience:
A patient with a biceps tendon rupture is likely to experience:
A patient reports sudden onset of pain in the anterior shoulder, radiating down the biceps muscle, following a strenuous lifting activity. On examination, a visible bulge is noted in the distal upper arm. What is the MOST likely diagnosis?
A patient reports sudden onset of pain in the anterior shoulder, radiating down the biceps muscle, following a strenuous lifting activity. On examination, a visible bulge is noted in the distal upper arm. What is the MOST likely diagnosis?
In the extremely rare event that all treatment options for Biceps Tendon Rupture have been exhausted and the patient expresses their desire to return to a high demand occupation, what is the MOST likely final option?
In the extremely rare event that all treatment options for Biceps Tendon Rupture have been exhausted and the patient expresses their desire to return to a high demand occupation, what is the MOST likely final option?
Flashcards
Dislocation
Dislocation
Humeral head separates from glenoid fossa.
Glenohumeral dislocation
Glenohumeral dislocation
Anterior, due to trauma like a blow to an abducted, externally rotated, and extended arm or overuse.
Dislocation signs/symptoms
Dislocation signs/symptoms
Obvious dislocation, pain, weakness, numbness/tingling.
Focused dislocation history
Focused dislocation history
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Dislocation physical exam
Dislocation physical exam
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AC separation
AC separation
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Manual reduction
Manual reduction
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Dislocation treatment
Dislocation treatment
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Dislocation recovery expectations
Dislocation recovery expectations
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Adhesive capsulitis
Adhesive capsulitis
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Adhesive capsulitis symptoms
Adhesive capsulitis symptoms
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Adhesive Capsulitis Exam
Adhesive Capsulitis Exam
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Impingement Syndrome
Impingement Syndrome
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Adhesive Capsulitis Treatment
Adhesive Capsulitis Treatment
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Adhesive Capsulitis expectations
Adhesive Capsulitis expectations
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Brachial Plexus Injury Cause
Brachial Plexus Injury Cause
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Brachial plexus signs/symptoms
Brachial plexus signs/symptoms
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Focused brachial plexus history
Focused brachial plexus history
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Brachial plexus physical exam
Brachial plexus physical exam
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Brachial plexus differentials
Brachial plexus differentials
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Brachial plexus care
Brachial plexus care
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Brachial plexus expectations
Brachial plexus expectations
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Biceps Tendon Rupture location
Biceps Tendon Rupture location
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Biceps Tendon Rupture signs/symptoms
Biceps Tendon Rupture signs/symptoms
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Bicep rupture histories
Bicep rupture histories
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Bicep Rupture exams
Bicep Rupture exams
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Rule-outs for a ruptured biceps
Rule-outs for a ruptured biceps
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Bicep rupture treatments
Bicep rupture treatments
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Bicep tendon expectations
Bicep tendon expectations
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Lateral epicondylitis
Lateral epicondylitis
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Lateral epicondylitis Symptoms
Lateral epicondylitis Symptoms
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Lateral epicondylitis exam
Lateral epicondylitis exam
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Lateral epicond differentials
Lateral epicond differentials
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Lateral elbow treatments
Lateral elbow treatments
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Lateral epicond expectations
Lateral epicond expectations
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Bursitis
Bursitis
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Bursitis signs/symptoms
Bursitis signs/symptoms
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Bursistis differentials
Bursistis differentials
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Care for bursistis
Care for bursistis
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Scaphoid fracture
Scaphoid fracture
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Scaphoid fracture: signs/symptoms, exams
Scaphoid fracture: signs/symptoms, exams
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Scaphoid: differentials
Scaphoid: differentials
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Scaphoid protection
Scaphoid protection
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Carpal tunnel syndrome (CTS)
Carpal tunnel syndrome (CTS)
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CTS signs/symptoms
CTS signs/symptoms
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CTS differentials
CTS differentials
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CPS Care action
CPS Care action
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De Quervains tenosynovitis
De Quervains tenosynovitis
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Degenerative History
Degenerative History
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Study Notes
Dislocation
- Dislocation is when the humeral head separates from the glenoid fossa.
- 95% of all glenohumeral (shoulder) dislocations are anterior.
- Shoulder dislocation occurs because of trauma, as a blow to the abducted, externally rotated, and extended arm or long-term overuse and abuse of the rotator cuff muscles, such as seen in throwing/racquet athletes.
Signs and Symptoms
- Obvious dislocation
- Pain
- Weakness
- Numbness or tingling in the affected extremity may suggest nerve injury
Focused History
- Hand dominance.
- History of injury/prior dislocation
- History of throwing or racket sports
- Occupation
- Numbness, tingling, weakness in the affected extremity
Physical Exam
- Obvious deformity with humeral head anterior
- Tenderness to palpation of the affected area
- Arm held in externally rotated, slightly abducted position.
- Consider posterior dislocation if the arm is being held internally rotated.
- Reduced ROM or unable to perform ROM
- Positive apprehension test with possible O'Brien test positive in SLAP lesion.
Tools
- X-rays can be used, if available, to evaluate for possible fracture
Differential Diagnosis
- Shoulder subluxation (partial dislocation) presents when the shoulder has spontaneously reduced, with no obvious signs remaining aside from residual pain/discomfort.
- Shoulder impingement presents with no deformity.
- AC separation presents after trauma with reduced ROM of shoulder, tenderness to palpation over the AC joint but not the shoulder.
- Rotator cuff pathology will likely have rotator cuff damage.
Treatment and Management
- Manual reductions require a trained medical professional, occasionally under sedation.
- Evaluate neurovascular status and stabilize the extremity prior to transport.
- Use a sling for the first 2-4 weeks after injury.
- Gentle stretching throughout ROM once pain subsides, as directed by physical therapy if initial dislocation occurred.
- PRICE
- NSAIDs
- Battlefield Acupuncture (BFA)
Reduction Techniques
- External rotation technique: http://www.uptodate.com/contents/image?imageKey=EM/81132&source=graphics_search&rank=20~27&search=
- Cunningham Technique: https://www.youtube.com/watch?v=kYYI1fN3gRU
- Traction-Countertraction: https://www.youtube.com/watch?v=HEVtYiVAZnU
Follow-Up
- Mild reduction in ROM and possible pain may be present for 4-6 weeks following injury.
- Avoid aggravating activities.
- Follow physical therapy regimen as recommended.
- Follow-up Actions:
- Follow-up in 2 days, consider referral to physical therapy if available or seek their guidance.
- EVAC/orthopedics if there is no improvement after 6 weeks of conservative therapy
Blue Directive
- Contact Preceptor Immediately
Adhesive Capsulitis
- Also known as "frozen shoulder."
- Adhesive capsulitis is described as a very painful shoulder that is triggered by minimal or no trauma.
- This self-limiting disease can be very debilitating.
Three Phases of Adhesive Capsulitis
- Initial phase: 2-9 months, development of diffuse, severe, and disabling shoulder pain, worse at night
- Intermediate phase: 4-12 months, stiffness and severe ROM loss, gradually less pain
- Recovery phase: Takes from 5-24 months, gradual return of ROM
Demographics
- Adhesive capsulitis is seen commonly in patients 40 to 65 years old and is more common in women
Signs and Symptoms
- Severe, nagging pain at night
- Progressive global stiffness
- Limited range of motion and activities of daily living
Focused History
- Onset of adhesive capsulitis is important and can be helpful in its diagnosis.
- Insidious onset is more common.
- Traumatic onset of adhesive capsulitis is unlikely.
- Hand dominance
- Occupation
Physical Exam
- Tenderness to palpation about the shoulder
- There will likely be no obvious cause
- Limited external rotation is a useful clinical indicator.
- Typically, a firm, painful, and premature end to passive ROM
- Strength is usually normal, but can be diminished when the patient is in pain.
Differential Diagnosis
- Impingement syndrome: active range of motion will be reduced but passive range of motion will be full.
- Shoulder dislocation: patient will be in a great deal of pain and unlikely to be able to perform range of motion.
- AC joint separation: history of trauma and cross body adduction will be painful
- Tendinitis: history will likely indicate overuse
Treatment and Management.
- Do not vigorously manipulate shoulder
- Gentle range of motion exercises
- NSAIDS
- Battlefield Acupuncture (BFA)
- Refer to physical therapy if available
Follow-Up Actions
- Avoid aggravating activities.
- Follow physical therapy regimen as recommended.
- Follow-up Weekly: Follow-up in clinic with range of motion evaluation and advancement of physical therapy exercises as necessary
- EVAC/orthopedics if there is no progress or worsening of symptoms in six weeks.
Blue Directive
- Contact Preceptor
Brachial Plexus Injury
- Consists of several nerve roots intertwined with each other.
- An injury may not fit the typical symptom pattern of an individual nerve injury and may incorporate symptoms in several dermatomes.
- The most likely cause of injury is trauma ("stinger" or "burner").
Signs and Symptoms
- Most likely one-sided
- Extremity pain in an unusual pattern
- Numbness and tingling
- Weakness
- Symptom onset may be acute to insidious
Focused History
- History of trauma (most common cause)
- Fall that forces the head away from the shoulder.
- History of cancer or cancer treatment.
- Associated symptoms in hand, wrist, or elbow
Physical Exam
- Motor/sensory deficits in an atypical pattern
- Possibly affecting the entire extremity
- Diminished reflexes in the affected limb
- Weakness as compared to the unaffected side
- Scapular winging
- Shoulder muscle atrophy
Differential Diagnosis
- Cervical radiculopathy: pain may radiate from or to neck and shoulder
- Trauma: mechanism of action
Treatment and Management
- Assess for neck/head trauma
- Limit lifting
- Avoid aggravating activities
- NSAIDS
- Battlefield Acupuncture (BFA)
- In some cases, surgery may be required
Follow-up Actions
- Avoid aggravating activities
- Daily follow-up is essential
- It is likely a self-limiting problem, but may take up to 6 months
- Take medications as directed, if indicated
- Symptoms (pain, weakness, etc.) will generally improve over time
- If improving daily, continue to monitor
- EVAC/orthopedics consult if no improvement in 5-7 days
Blue Directive
- Contact Preceptor
Bicep Tendon Rupture
- Rupture commonly occurs at the proximal long head of the biceps tendon.
- Proximal long head of the biceps tendon may be involved due to impingement or instability.
Symptoms
- Sudden pain in the upper arm (anterior shoulder with radiation over the biceps muscle)
- Audible pop may be heard
- Bulging of the muscle is possible ("Popeye” deformity)
Focused History
- Hand dominance
- History of injury
- History of throwing or racket sports
- History of impingement or instability
- Occupation
Physical Exam findings
- Bulge in the lower arm may be appreciated.
- May be accentuated by having flexed biceps.
- Proximal defect may be palpated.
- Tenderness to palpation at bicipital groove.
- Speed's and Yergason's tests may help assess for tendinopathy or strain.
Tools
- X-Ray may help rule out fracture.
Differential Diagnosis
- Dislocation of the biceps tendon: tender to palpation over bicipital groove but no noted bulge in lower arm.
- Distal biceps rupture: pain and ecchymosis distally with high-riding muscle belly.
- Impingement syndrome: often can cause biceps rupture.
- Rotator cuff tear: often can coexist with biceps rupture.
Treatment
- NSAIDS
- Battlefield Acupuncture (BFA)
- PRICE
- Refer to physical therapy if available
- EVAC/orthopedics
Follow up
- Mild loss of strength is possible in the affected arm.
- There may be a lasting cosmetic defect if not repaired.
- Daily follow-up to monitor patient for pain control while awaiting EVAC/orthopedics
Blue Directive
- Contact preceptor immediately.
Epicondylitis
- Lateral epicondylitis is also known as "Tennis Elbow," and medial epicondylitis is also known as "Golfer's Elbow".
- Lateral epicondylitis is far more common.
- Treatment is the same for both.
- Underlying mechanism of injury is chronic repetitive use of injury causing microtrauma at the tendon insertion; however, acute injuries can occur due to excessive loading.
Symptoms
- Lateral epicondylitis
- Pain in the extensor tendons of the forearm and around the lateral elbow when the wrist is extended against resistance
- Pain while shaking hands/turning jar lids, doorknobs
- Medial epicondylitis
- Pain in the flexor pronator tendons originating at the medial epicondyle when the wrist is flexed or pronated against resistance
- Pain with golfing, pitching, swimming
Focused History
- Hand dominance
- Recent trauma
- Repetitive actions
Physical Exam
- Tenderness to palpation over the affected epicondyle
- Resisted wrist extension will elicit pain for lateral epicondylitis
- Resisted wrist flexion and wrist pronation will elicit pain for medial epicondylitis
- Passive ROM can also elicit pain in either condition
Differential Diagnosis
- Cubital tunnel syndrome: compression of the ulnar nerve, paresthesia in ring and little fingers
- Radial head fracture: history of trauma, tenderness to palpation over the radial head exacerbated by pronation/supination
- Synovitis of the elbow: swelling, palpable fluid
- Triceps tendonitis: tender to palpation above the olecranon
Management
- Avoid aggravating activities
- Rest
- Ice/Heat (whichever relieves pain)
- NSAIDs
- Battlefield Acupuncture (BFA)
- Gentle stretching throughout ROM; eccentric strengthening exercises
- OTC tennis elbow bands for pain relief but not recovery
Treatment Algorithm
- Clinical diagnosis of either lateral or medial elbow tendinopathy
- Initial interventions:
- Activity modification of causative activities/exercises
- Use counterforce brace/compression sleeve if pt prefers
- Ice applied to epicondyle prn after activity
- Oral analgesics
- Wrist mobility exercises
- Eccentric strengthening exercises
- If exam reveals diminished elbow mobility, bony abnormalities, or other signs of injury or intra-articular pathology perform appropriate diagnostic imaging (generally 3-view elbow plain radiographs) and manage based on findings.
- Imaging should be done using elbow plain radiographs or Ultrasound
- With diagnosis of epicondylitis confirmed, re-assess exercise/compliance program, adjusting as required plus:
- Continue or expand exercise modifications
- Apply NTG topically
- Consider iontophoresis
- Give local GC injection for short-term severe pain, if needed; avoid additional injections Continued
- If pt is not improved with 3 months, consider percutaneous needle tenotomy, injectable biologics, or prolotherapy depending on availability
Follow-up Actions
- Follow prescribed stretching regimen consistently.
- Surgical treatment requires 9-12 months of consistent pain if unresolved with conservative methods
- If no improvement or only if condition is affecting ability to perform daily duties, consider orthopedics consult if available
Blue Directive
- Battlefield Acupuncture (BFA)
Green Directive
- Routine review by preceptor
- IAW 44-103, No BFA
Bursitis
- Acute or chronic inflammation of a bursa generally, from an unknown cause but may be secondary to trauma, infection, or arthritic conditions.
- Bursae are fluid-filled, sac-like cavities that overlie bony prominences where friction occurs in order to reduce it.
- Common places for bursitis include shoulder (subacromial bursitis), elbow (olecranon bursitis), hip (trochanteric bursitis), and knee (prepatellar bursitis).
- Prepatellar bursitis affects the anterior knee, and is also known as “housemaid's knee."
Signs and Symptoms
- Generally, a benign problem, but a hot, red, swollen, tender joint equals a septic joint until proven otherwise.
- Swelling at the affected joint.
- Pain, and is likely to be intense with injury or infection
- ROM limitation in some cases.
- Fever or constitutional symptoms indicate a possible septic joint.
- Superficial bursitis may appear erythematous and swollen, which may also suggest infection.
Focused History
- Hand dominance
- Trauma
- Previous episodes
- History of gout
Physical Exam
- Vital signs: should be normal; if febrile, consider septic joint etiology.
- Obvious swelling
- Signs of trauma
- Erythema and associated pus indicates infection.
- Exquisite tenderness to palpation generally indicates infection.
Tools
- X-ray can rule out possible fracture (if suspected).
Differential Diagnosis
- Fracture (traumatic injury).
- Gout: history of similar episodes and a diagnosis of gout
- Rheumatoid arthritis: multiple joint involvement
- Septic joint: fever, erythema, edema, warmth of joint, often holding joint (knee) in slight flexion to maximize joint space
Non-Infectious Treatment
- PRICE
- Avoid aggravating activities (overtraining, poor body mechanics, repetitive trauma, or tight or deconditioned muscles).
- NSAIDs
- Battlefield Acupuncture (BFA)
- Elbow/knee protectors for olecranon or prepatellar bursitis
Septic joint
- Transfer for orthopedic surgery consult
- Start IV antibiotics with preceptor or consultant recommendation.
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