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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Shoulder Special Tests Impingement Syndrome • Age 40 – 60
Instability/Labrum Issues • Apprehension: Possible torn labrum or anterior instability problem ○ Sensitivity = 30–53%; specificity = 63–99% Adhesive Capsulitis 1. Acute/freezing/painful phase (typically lasts 3–9 months): Gradual onset pain at rest with sharp pain at extremes ROM, and pain at night 2. Adhesive/frozen/stiffening phase (occurs at ~4 months; lasts ~12 months): Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern. Pain is apparent only at extremes ROM 3. Resolution/thawing phase (last ~1–3.5 years): Spontaneous, progressive improvement in functional range of motion • Eight clinical identifiers clustered into two discrete domains (pain and movement) as well as an age component ○ Pain ■ Strong component of night pain ■ Pain with rapid or unguarded movement ■ Discomfort lying on the affected shoulder ■ Pain easily aggravated by movement ○ Movement ■ Global loss of active and passive ROM ■ Pain at end-range in all directions ○ Age - Onset > 35 years of age
• Pain during elevation in anterior/ lateral shoulder; worse with overhead activities, does not radiate below elbow • Painful arc: between 60-120 degrees • Weakness • Hawkins–Kennedy: Supraspinatus tendon impingement: ○ Sensitivity = 72%; specificity = 66% • Neer impingement test: Subacromial impingement: ○ Sensitivity = 79%; specificity = 53% Rotator Cuff Injury • Empty can—integrity supraspinatu: ○ Sensitivity = 41–89%; specificity = 50–90% • Drop arm sign: Rotator cuff tear ○ Sensitivity = 27%; specificity = 88% • Apley scratch test: The patient attempts to touch the opposite scapula to test range of motion of the shoulder ○ Loss of range of motion = rotator cuff problem Biceps Tendon Involvement • Yergason’s: Biceps tendon instability or tendonitis ○ Sensitivity = 74%; specificity = 58%
Potential Shoulder Referral Patterns Area of Pain Possible Causes Left shoulder
• MI: 68.7% of patients reported shoulder pain during an acute myocardial infarction • Ruptured spleen
• Pancoast’s tumor • Carcinoma • Cirrhosis, hepatitis
Both shoulders Right shoulder
• Hiatal hernia • Peptic ulcer • Pancreatitis • Pancreatic cancer • Gall bladder • Cholecystitis: Typically accompanied by fever, or nausea/vomiting
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