Shoulder Impingement Evidence Based Case Study Rumy Petkov
Used evidence based literature to compare laser therapy treatment versus corticosteroid injections, ultrasound, rehab exercises, and Kinesio taping to treat shoulder impingement.
A course Review from James Moore's Sporting Hip and Groin Course - February 2016 (Highly Recommend!). Following my attendance of the course, i performed my own research on 'The Sporting Hip and Groin' and incorporated this into the course review which I presented to the Sports Science and Medicine staff at Wigan Athletic FC. Further references available upon request.
In this presentation I’m going to inform you briefly about a novel arthroscopic technique for athletic pubalgia. You may have heard it as “sports hernia or groin injury………” but in fact is a groin pain syndrome, particularly common in sports that require athletes to perform repetitive kicking..
Shoulder Impingement Evidence Based Case Study Rumy Petkov
Used evidence based literature to compare laser therapy treatment versus corticosteroid injections, ultrasound, rehab exercises, and Kinesio taping to treat shoulder impingement.
A course Review from James Moore's Sporting Hip and Groin Course - February 2016 (Highly Recommend!). Following my attendance of the course, i performed my own research on 'The Sporting Hip and Groin' and incorporated this into the course review which I presented to the Sports Science and Medicine staff at Wigan Athletic FC. Further references available upon request.
In this presentation I’m going to inform you briefly about a novel arthroscopic technique for athletic pubalgia. You may have heard it as “sports hernia or groin injury………” but in fact is a groin pain syndrome, particularly common in sports that require athletes to perform repetitive kicking..
examination,impingement syndrome,rotator cuff injury,shoulder,shoulder instability
All about orthopaedic shoulder examination. comprehensive ppt with all tests arranged symptom wise
The objective of this in-service presentation was to provided inpatient physical therapists and occupational therapists with the clinical decision making skills to properly evaluate common orthopedic dysfunctions encountered in the acute care setting.
Phased approach of Connecting from posture and movement assessment (1).pdfTomohiro Sawatari
I am a physiotherapist in Japan. I used to work in a conditioning gym and since I got my physiotherapy licence I have been working in an orthopaedic clinic.
The postural and movement assessment as a concept for therapeutic intervention is summarised in this slide.
---------------------------------------------------------
姿勢・動作の評価の考え方について、このスライドにまとめています。
ACL Injury Hacks covers the entire physiology, etiology,pathology, diagnosis, recent advancements in diagnosis of ACL and focus on how an early and accurate diagnosis can contribute to a better treatment and rehabilitation as well as early return to sport of an athlete.
Similar to Shoulder clinical tests validity eleanor richardson (20)
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
Should We Repair Rotator Cuff Tears OPN 2017.pdfLennard Funk
Lennard Funk & Puneet Monga
Prepared for Orthopaedic Product News, 2017
Rotator cuff disease is very common. There is as much enthusiastic discussion and debate on its management as there was 80 years ago when Codman (1937) first described the pathology and surgical management. There is great variation amongst surgeons as to the management of rotator cuff tears biased by experience and their understanding of the literature, skills levels and regional variations. There has been a lot of research done on the pathology, non-operative and operative treatments over the last two decades. Also, over the last decade there have been massive strides in the development of new surgical techniques and technologies. However, despite these advances there is as much discussion and debate!
Superior Capsular Reconstruction Outcomes Wrightington 2020Lennard Funk
Hariharan Mohan, Jagwant Singh, Michael Walton, Lennard Funk, Puneet Monga
Cautious optimism following SCR may be offered to this challenging subset of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery. Further studies with longer term followup are recommended.
Isolated scapula pain is uncommon, but very difficult to diagnose and manage. In this presentation I run through the known causes and an approach to the diagnosis, in order to guide best treatment.
The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Un...Lennard Funk
Presentation at ISAKOS, 2019
There were 442 primary arthroscopic labral repair procedures performed over the three-year period. The total cohort had a mean age of 25.91±9.09 years (range, 14-67 years) and consisted of 89.6% males. There was no significant difference in mean age or gender between the isolated anterior, posterior or combined groups (p=0.383 and p=0.541, respectively).
• Of the 442 patients who underwent a shoulder labral repair, isolated anterior labral pathology occurred in 52.9% (n=234), with posterior and combined labral tears accounting for 16.3% (n=72) and 30.8%, respectively (n=136) (Table 3).
• Patients were stratified as either sporting or non-sporting; 74.9% of patients were categorised as sporting (n=331) and had a mean age of 24.91±5.69 years, which was significantly lower than the mean age of 35.40±11.94 years in the non-sporting population (p<0.001). In the non-sporting population 68.5% (n=76) of patients had isolated anterior labral tears with 12.6% (n=14) posterior and 18.9% (n=21) combined. In the sporting population isolated anterior labral tears accounted for 47.7% (n=158), posterior 17.5% (n=58) and combined labral tears 34.7% (n=115). The sporting population had a significantly greater proportion of posterior and combined labral tears with the non-sporting population a significantly greater proportion of anterior labral tears (p=0.013).
• Rugby players had the greatest incidence of shoulder instability within the sporting cohort accounting for 231 cases. Of the 231 cases, 47.2% were isolated anterior labral tears, 12.6% isolated posterior and 40.3% combined lesions.
Posterior and combined shoulder labral tears are more prevalent than previously reported in the civilian population. The rates are higher in young, sporting populations and especially in contact sports such as rugby.
Pectoralis major allograft reconstructionLennard Funk
Presentation at ISAKOS, 2019
We performed a total of 142 pectoralis major repairs over a ten year period, of which 19 required allograft reconstruction. Of these 19 patients, 11 were available for response. All 11 patients were male with a mean age of 38.3 years (21 to 48 years). The mean time between injury and surgery was 12.2 months (4 to 30 months). Ten patients (91%) were unable to perform their previous level of work pre-operatively, with all patients returning to pre-injury occupation levels post-operatively.
The main complaint prior to surgery was pain on pushing and moving the affected arm across the body, which improved in nine patients (82%), with no improvement reported in two patients. Strength improved significantly post-operatively, with only three patients reporting no improvement (paired t-test p=0.01). Six patients reported an improvement in cosmesis (50%).
Hydrodistention is a treatment for frozen shoulder (FS) that is gaining popularity again. However, no large, long-term outcome data has been published yet. Our aims were to evaluate hydrodistension for the treatment of primary frozen shoulder (FS) in a large cohort of patients with long follow-up period.
We present a case series of eighty-nine patients (36 males and 53 females) with a mean age of 52 years (33-73). Eleven (12.4%) had disease associations. We excluded post-operative secondary stiff shoulders. The mean volume injected was 33.7ml (16-66). 36/89 (40%) had capsular rupture. Six (6.7%) had adverse effects. The mean follow-up was 104.5 weeks (8-238).
Mean improvement in forward flexion was 165.4, abduction 111.6, external rotation was hand above head with elbow back (and internal rotation in extension to T12. Mean improvement in quickDASH score was 17.1 (p<0.001) and Constant Score was 70.0 (p<0.001). Mean improvement in VAS was 7.3 (p<0.001). No patients had night pain (p<0.001). Eighty-eight (99%) returned to their previous occupation. Seventy-six (85%) returned to their previous level of sport. Gender, previous intra-articular steroid injection, volume of the injectate, type of steroid used, capsular rupture and underlying aetiology had no impact on outcome.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
1.
Clinical Assessment of the
Shoulder:
What the research says…
Eleanor Richardson
Senior MSK Physiotherapist
2015
2. Are the Clinical Tests we use Valid?
Sensitivity
“SNOUT”:
➢ A sensitive test can rule out a
disease when the result is
negative
● A sensitive test = sensitivity >
80%, -LR < 0.20
Specificity
“SPIN”:
➢ A very specific test rules in a
disease with a high degree of
confidence
● A specific test = specificity >
80%, +LR > 5.0
3. SLAP lesions
● Hegedus et al. (2012):
Passive Distraction and Active
Compression = s:70% sp: 90%,
+ve LR:7.0, –ve LR: 0.11
(Schlecter, 2009)
Compression-rotation AND
Apprehension AND Speed = s:
25%, sp: 92%, +LR: 3.13, -LR:
0.82 for Type 2 only (Oh et al.
2008)
➢ Less optimism for Biceps load
II than in Hegedus (2008)
● MRI may be helpful but
anatomical variants and
Buford complex are normal
● MRI and MR Arthrogram
imaging have lower sensitivity
than physical examination
tests in diagnosing SLAP
lesions
➢ in others words, both
negative scans and negative
cluster testing does NOT rule
out a SLAP lesion
4. Labral Pathology (not exclusive to SLAP)
● Hegedus et al. (2012):
Anterior Slide AND Crank = s:
34%, sp: 91%, +LR: 3.75, -LR:
0.73 (Walsworth et al., 2008)
Apprehension AND Relocation
= s: 38%, sp: 93%, +LR: 5.43, -
LR: 0.67 (Gaunche & Jones,
2003)
➢ These combinations are good
at ruling IN labral pathology
but a negative test cannot
confidently this rule out…
● Munro (2009):
Kim = s: 80%, sp: 93%, +LR:
12.6, -LR:0.21 (Kim, 2005)
Jerk = s: 73%, sp: 98%, +LR:
34.7, -LR: 0.21 (Kim, 2005)
IRRT (differentiate intra-articular
pathology from impingement) =
s: 88%, sp: 96%, +LR: 24.7, -LR:
0.12 (Zaslav, 2001)
5. Rotator Cuff Tears
● Hegedus et al. (2012):
Age ≥ 65 AND Weakness in ER
(infraspinatus) AND night pain
= s: 49%, sp: 95%, +LR: 9.84, -
LR: 0.54 (Litaker, 2000)
Lift off and/or resisted IR
(subscapularis) = s: 50%, sp:
95%, +LR: 10.0, -LR: 0.53
(Naredo, 2002)
● Hegedus (2008):
Recommend a combination of
bear hug & belly press (s:
40-60%, sp: 88-98%)
● Miller et al. (2008):
ERLS for SSP & ISP, s: 46%, sp:
94%
➢ Tests here appear to be good
at ruling in an RCT but a
negative test does not mean
a RCT/pathology does not
exist
6. AC joint
● No clinical test met the
criteria for recommendation
by Hegedus (2012) due to
high risk of bias from
QUADAS 2 assessment
● Two studies looked at clinical
tests for the AC joint: Jia et al.
(2009) & Goyal et al. (2010)
● Jia et al. (2009) found:
● AC resisted extension = s:
72%, sp: 85%, +ve LR:4.8 -
LR: 0.33
● Active Compression for AC =
s: 41%, sp: 95%, +LR: 8.2, -
LR: 0.62
● Cross body for AC joint = s:
77%, sp: 79%, +LR: 3.67, -
LR: 0.29
● Goyal et al. (2010) found:
● Adductor stress = s: 57%, sp:
96%, +LR:15, -LR: 0.45
7. And now for the less well
defined pathologies….
8. Subacromial Impingement Syndrome (SIS)
● Hegedus et al. (2012):
At least 3 or more positives of
the following: Hawkins-
Kennedy, Neer, Painful Arch,
Empty Can, resisted ER = s:
75%, sp: 74%, +LR: 2.93 and –
LR: 0.34 (Michener et al., 2009)
● Park et al. (2005) also
recommend this cluster but
without the arch sign
● Even with cluster testing
adequate levels of sensitivity,
specificity, positive & negative
LRs are not reached for SIS
● However, consider relevance
as would this inform clinical
decision making?
● Structural Vs Patterning?
● Consider SSMP (Lewis, 2009)
and neuromodulation/
patterning re-education
9. Rotator Cuff Tendinopathy
● Hegedus et al. (2012):
Age > 39, Painful Arch, Self-
report of popping or clicking
(Chew et al. 2010):
➢ 2 or more positives= s:
75%, sp: 81%, +LR: 3.82 -
LR: 0.32
➢ 3 positives = s: 38%, sp:
99%, +LR: 32.20, -LR: 0.63
Lift off and/or Resisted IR = s:
50%, sp: 84%, +LR: 3.13, -LR:
0.60 (Naredo et al, 2002)
However…
● Inadequate sensitivity means
a negative test does not
mean a tendinopathy doe not
exist
● Large cross over with RCT
and SIS
● Difficult to evaluate the use of
cluster testing in light of Cook
and Purdum’s (2009)
tendinopathy continuum
10. Shoulder Instability
● Hegedus et al. (2012) Strong
evidence only for Type 1 – 2
anterior instability (Stanmore)
Apprehension and Relocation = s:
81%, sp: 98%, +LR: 39.68, -LR:
0.19 (Farber et al. 2006)
EUA:
● Laxity (Colfield’s technique):
● Ant/post drawer signs
● Sulcus sign & Gagey Test for
inferior capsule/Rotator interval
For atraumatic instabilities (type III)
consider:
● Muscle patterning
● Kinetic Chain
● Beighton score
➢ Load and shift (no data)
➢ Ant/Post draw (no data)
11. Adhesive Capsulitis
● Not assessed as current
diagnosis is clinical so no
criterion standard
● Hegedus et al. (2012):
Shrug Sign appears sensitive for
stiffness related disorders (OA
and adhesive capsulitis)(Jia et al,
2008)
➢ Essential physical criteria for
diagnosis is a marked and
equal limitation of External
rotation, both passively and
actively
● Emig et al. (1995):
MR Arthrogram sensitivity of
70% and a specificity of 95%
➢ Difficult to interpret as etiology
and histology is not fully
understood
12. Osteoarthritis
● No data for sensitivity or
specificity for clinical shoulder
tests
● Based on clinical history,
presentation and XRAY
● >50yrs, incidence increase with
age
● Insidious and progressively
worsening
● Pain: activity dependent, usually
intermittent but can be at rest,
dull generalised aching, night
pain, reduced active and passive
ROM all planes, esp. ER, disuse
atrophy, possible grinding
sensation with joint movements
● XRAYs:
● Subchrondral sclerosis +/- cysts
● Osteophytes
● For the knee 24-56% of patients
with OA X-ray findings have pain
and higher grades of OA are
linked with pain ?relevant to
shoulder, a none weight bearing
joint?
(Parsons et al., 2004)
13. The best* test combinations and reported values…
● SLAP: Passive Distraction AND Active Compression
● SLAP (T2): Compression-rotation AND Apprehension AND Speed
● Labral Tear: Anterior Slide AND Crank AND/OR Apprehension AND
Relocation
● RCT (degen): Age≥65 AND weakness in ER AND night pain
● RCT (none degen): Lift-off and/or Resisted ER
● SIS: Hawkins-Kennedy, Neer, Painful Arch, Empty Can, Resisted ER (3 or
more positives)
● RC Tendinopathy (supra): Age > 39, Painful Arch, self-report of popping
or clicking
● RC Tendinopathy (subscap): Lift-off and/or Resisted IR
● Anterior Instability (T1): Apprehension AND Relocation
*Defined as highest sensitivity, specificity, or both from studies with least bias
14. References
● Hegedus et al. (2012) Which physical examination tests provide clinicians with the most value when examining the
shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med, Nov;46(14):964-78
● Hegedus et al. (2008) Physical examination tests of the shoulder: a systematic review with meta-analysis of individual
tests. Br J Sports Med, 42: 80-92
● Oh et al. (2008) The Evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and
posterior lesion, Am J Sports Med, 36 (2): 353-359
● Walsworth et al. (2008) Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid
labral tears, Am J Sports Med, 36: 162-8
● Guanche & Jones (2003) Clinical testing for tears of the glenoid labrum, Arthroscopy, 19: 517-23
● Munro & Healy (2009) The validity and accuracy of clinical tests used to detect labral pathology of the shoulder – a
systematic review, Manual Therapy, 14:119-30
● Zaslav (2001) Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from
outlet (Neer) impingement syndrome in the shoulder, Journal of Shoulder & Elbow Surgery, 10(1):23-7
● Litaker et al. (2000) Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am
Geriatric Soc, 48: 1633-7
● Naredo et al. (2002) Painful shoulder: comparison of physical examination and ultrasonographic findings. ANN Rheum
Dis, 61: 132-6
● Miller et al. (2008) The validity of the lag sing in diagnosing full thickness tears of the rotator cuff: a preliminary
investigation. Archives of Physical Medicine & Rehabilitation, 89(6): 1162-1168
15. References cont…
● Michener et al. (2009) Reliability and diagnostic accuracy of 5 physical examination tests for subacromial
impingement. Arch Phys Med & Rehabilitation, 90: 1898-903
● Park et al. (2005) Diagnostic accuracy of clinical tests for different degrees if impingement, JBJS
American, 87: 1446-1455
● Lewis JS. Rotator cuff tendinopathy. Br J Sports Med. 2009 Apr;43(4):236-41.
● Lewis, J. S. (2009) Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new
method of assessment? British Journal of Sports Medicine, Vol 43, pp. 259-264
● Lewis JS. Rotator cuff tendinopathy: a model for the continuum of pathology and related management.
Br J Sports Med. 2010 Oct;44(13):918-23. http://bjsm.bmj.com/content/44/13/918
● Lewis JS, Tennent TD. How effective are diagnostic tests for the assessment of rotator cuff disease of
the shoulder? In: MacAuley D, Best TM, editors. Evidenced Based Sports Medicine. 2nd ed. London:
Blackwell Publishing; 2007.
● Farber et al. (2006) Clinical assessment of three common tests for traumatic anterior shoulder instability,
J Bone Joint Surg Am, 88: 1467-74
● Emig et al. (1995) Adhesive capsulitis of the shoulder: MR diagnosis, Am J Roenthenol, 164(6): 1457-9
● Parsons et al. (2004) Glenohumeral arthritis and its management, Physical Medicine and Rehab Clinics
of North America, 15: 447-474
16. References cont…
● Jia et al. (2009) Examination of the shoulder: the past, the present and the future. J Bone Joint surg Am,
91(6): 10-8
● Jia et al. (2008) Clinical evaluation of the shrug sign. Clin Orthop Relap Res, 466:2813-9
● Goyal et al. (2010) High resolution sonographic evaluation of the painful shoulder. Internat J Radiology.
12:22
● Chew et al, (2010) Cinical predictions for the diagnosis of supraspinatus pathology, Physiotherapy
Singapore, 13: 12-17
● Cook & Purdum (2009) Is tendon pathology a continuum? A pathology model to explain the clinical
presentation of load-induced tendinopathy. Br J Sports Med, 43(6): 406-16