January Journal Club

[Taylor Blattenberger]

Hey all,

Sorry for the late post.

Please answer these questions to initiate some thoughts and discussion:

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?

2) Are there any objective tests you feel would provide a clearer picture of this case?

3) Do the objective findings fit a clinical pattern? If so, of what?

4) What impairment or limitation would you want to address first with this patient?

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[helenrshep]

1) labral tear (instability); RTC tendinopathy, bicep tendinopathy

2) GH and scapulothoracic joint mobility; Speeds Test

3) Likely shoulder instability, possibly due to labral pathology/tear.

4) If we’re thinking instability, I’d probably start with some proprioceptive exercises or provide perturbations in a pain free range (maybe supine at 90 degrees flexion) to start to work on stability.

[awilson12]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
AC joint pathology, labral pathology, RTC or biceps tendinopathy or tear

2) Are there any objective tests you feel would provide a clearer picture of this case?
horizontal adduction and AC joint compression test; passive range of motion and joint mobility assessment to determine cause of end range limitations

3) Do the objective findings fit a clinical pattern? If so, of what?
Based on this information seems like findings are in line with shoulder instability with associated labral pathology and RTC involvement

4) What impairment or limitation would you want to address first with this patient?
I would tackle the RTC weakness first to get those muscles turned on to help with shoulder stability

[Steven Lagasse]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
Primary: Labral Pathology

Differentials:
– Myofascial / Cuff or biceps
– Impingement

2) Are there any objective tests you feel would provide a clearer picture of this case?
– Speed’s Test
– Palpation to RC mm
– Painful arc

3) Do the objective findings fit a clinical pattern? If so, of what?
Overall, yes the objective findings appear to fit the clinical pattern of labral pathology. Could also have a rotator cuff component.

4) What impairment or limitation would you want to address first with this patient?

Strengthening of the cuff and other stabilizing mm.

[pbarrettcoleman]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?

– Labral pathology
– Secondary Impingement
– RTC Tendinopathy

2) Are there any objective tests you feel would provide a clearer picture of this case?

Due to his scap having observational/movement impairments, assessing the PAM of shoulder blade. Also, what’s the MMT of those force couples involving the shoulder blade (LT/MT)? I’d expect based on the “pattern” that his humeral head is sitting too far forward — what’s his GH IR and posterior glide of GH Jt look like?

3) Do the objective findings fit a clinical pattern? If so, of what?

Yes – Labral pathology with some concomitant irritation to RTC.

4) What impairment or limitation would you want to address first with this patient?

Pending the results of PAM and some other things, I would focus on posterior glides (THE glide) to get that thing sitting back where it needs to then following up with exercise.

[lacarroll]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
– Primary: labral pathology
– DiffDx: secondary impingement, rotator cuff pathology

2) Are there any objective tests you feel would provide a clearer picture of this case?
– Sulcus sign, pivot shift, shoulder adduction, GH mobility, scap mobility

3) Do the objective findings fit a clinical pattern? If so, of what?
– Seems to fit with shoulder instability secondary to labral pathology

4) What impairment or limitation would you want to address first with this patient?
– Activation of cuff musculature and closed chain scap girdle stability.

[Michael McMurray]

1) Based on the Subjective History, what is your primary hypothesis and top 2-3 differentials?
Primary: Labral Pathology
Differentials: Rotator cuff tear, Impingement

2) Are there any objective tests you feel would provide a clearer picture of this case?
– APR of cervical spine and shoulder
– Rotator cuff: palpation, painful arc, ER lag sign, jobe, drop arm
– Impingement: HK, scapular assist, painful arc
– Labral (rule in): apprehension/relocation, crank, speeds, load and shift

3) Do the objective findings fit a clinical pattern? If so, of what?
Pattern seems to fit with labral pathology, with positive special testing and subjective reporting of instability

4) What impairment or limitation would you want to address first with this patient?
Improving strength and NM activation of rotator cuff musculature to improve active stability of L shoulder joint.

[lacarroll]

So I know Anna and I came in late and we may have missed this, but what caused the guy to come back in after a traumatic dislocation 10 years ago? Was there a more recent mechanism that irritated him or new job or whatever it may have been that made him seek out medical treatment now vs 10 years ago?

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