This image is of a male defensive back who injured shoulder after an arm tackle in recent game.
He felt pain and immediate dead arm which lasted 5 min. He has since had pain with ER and abduction movements. Additionally he feels as though his shoulder will give out.
What view are you looking at? What pathology exists and how can you tell?
Make sure you look very closely at the outlines of bony structures!
If he is now a week out - what should you be doing regarding therapy?
How conservative or aggressive should you be?
This appears to be an AC joint sprain with possible AC joint displacement. There is increased joint space and the clavicle is elevated. Pain occurs with abduction and MOI of a direct blow to the shoulder, which are consistent with an AC sprain. The radiograph shows a AP view, indicated by the R in the corner because the patient is facing us. Additionally, the scapula is behind the ribs. One week out, he should be treated conservatively with protective taping, cryotherapy, and soft tissue massage. Begin with simple exercises such as shoulder blade squeezes, pendulum, "wall walking" for gradual overhead motion as tolerated, and isometric shoulder strengthening. Progress as tolerated, adding in joint mobs and increased resistance. Treatment should be conservative to allow adequate time for healing.
ReplyDeleteI agree with Lindsay that this is an AP view. However, while there may be a small AC sprain, I believe I see something around the inferior glenoid fossa that could be a fracture. This would be consistent with his pain in abduction and ER as well as his feeling that his shoulder will give out, as a fractured glenoid fossa or rim could contribute to inferior instability. It does not appear to be significantly displaced, although a CT scan might show it better. The patient could begin gentle ROM exercises, but treatment should be conservative.
ReplyDeleteThis is an AP view of the right shoulder. The pt appears to have an AC joint sprain (possibly type 2), Bankart lesion, and possibly a SLAP lesion. Hill-Sachs lesion may also exist knowing the history, and there is a small opaque outline located on the humeral head. You can see that the clavicle is subluxed superior to the acromion process. There is also increased radiopacity at the anteroinferior and anterosuperior glenoid rim. With the history of the injury, I suspect the pt suffered an anterior dislocation of the glenohumeral joint with concomitant AC sprain. Being a week out and assuming the pt will respond to conservative treatment, begin light rotator cuff isometrics and scapular stabilization exercises. Also light elbow flexion/extension and gripping exercises to promote blood flow. Later progress as tolerated to resisted rotator cuff AROM, and posterior capsule mobilization techniques. Treatment should be fairly conservative to allow damaged tissues to heal.
ReplyDeleteI agree that this is an AP view of the right shoulder in internal rotation. I also agree that there is a Hill-Sachs lesion present on the humeral head likely due to dislocation of the shoulder. There also seems to be an irregularity of the inferior glenoid that could be due to bankart lesion/chondral lesion or even a fracture. Bankart's are commonly seen with anterior dislocation. The clavicle does appear to be a little high & therefore there may also be a mild to moderate AC sprain as well. Treatment for a dislocation is immobilization for 4 to 6 weeks, preferably in internal rotation with a Hill-Sachs lesion in order to not reinjure the area. Immobilization is necessary to avoid a loose shoulder & repeated dislocations. During this time, elbow & wrist ROM & gripping exercises can occur right away. Gradual progression of ROM of shoulder will occur after immobilization is complete. Rotator cuff isometrics & light resistance therex of the shoulder will occur with progression. Scapular exercises should also be incorporated. Some therex may be adjusted to surgical protocol if surgery is required. Further imaging may be needed to determine if surgery is required (eg. MRI).
ReplyDeleteThe image is of the right shoulder in internal rotation anterior to posterior. It appears that the athlete has a Hill Sachs lesion, likely resulting from a Bankart lesion, in the posterolateral margin of the humeral head. It also appears that there is deformation of the inferior glenoid, which could possibly be a fracture. A mild step deformity appears to be present indicating mild AC joint sprain. Gentle, painfree ROM should be started and possibly painfree submaximal isometrics as therapy should be conservative.
ReplyDeleteThe image is an AP view of the right shoulder. I agree with most so far that there is an AC joint sprain (probably grade III-IV if going off the 7 level scale). Considering the MOI, especially in a high-contact sport like football, a dislocation or subluxation probably occurred and resulted in a Hill-Sachs lesion. This lesion can be seen on the indentation of the humeral head on the radiograph. With the patient only being 1 week out, conservative treatment is the name of the game. Adequate time for tissue healing needs to be a top consideration, otherwise the patient could just end up dislocating again. Painfree PROM or even AAROM can begin but ER and shoulder extension should be avoided at this time.
ReplyDeleteThis appears to be an AP view of the R shoulder with the shoulder IR in order to identify the pathology. The pathology is a Hill-Sachs lesion with the tale-tale sign of the posteriolateral margin of the humeral head indention which was created when the humeral head was anterior dislocated over the glenoid rim anteriorly. The anterior side of the joint reveals meniscoid fluid which could indicate trauma. Also visible appears to be an AC sprain due to the mal-alignment of the Acromion and distal end of the clavicle. Since Hill Sachs lesions are 80% traumatic, and can also have neuropraxic symptoms (due to neuropraxia of the axillary nerve) this matches up with the patient being hit (traumatic injury) and reporting a "dead" arm.
DeleteTreatment should consist of formost avoiding ER and ABD initially, and focusing on all the components that help create stability around the shoulder; contractile, non-contractile, and proprioception (neuromuscular). Idealy starting with some very basic wrist and elbow ROM and strengthening, working into diminishing pain, normalizing motion, restoring proprioception, and establishing muscular balance to help hold the humeral head in the correct position to limit another dislocation.
I agree with Michael and Kilah. This is an AP with IR view. You can clearly see the greater tuberosity in profile with the scapula posterior to the rib cage. A dislocation/sublexation is very likely from the MOI. Often this results in a Bankart with subsequent Hill-Sachs lesion. This combination of injuries with account for the s/s described by the patient. Early immobilization with PROM to regain stability and maintain ROM is nescessary. Kilah brings up a good point with focusing on the different aspects of stability and muscular balance. I would also avoid performing joint mobilizations initially to allow healing to occur and secondary to joint instability following the injury. I would treat this patient conservatively. Many of my class mates have outlined very good progressions for conservative treatment.
DeleteThe radiograph demonstrates an AP internal rotation projection. I believe the primary pathology is a Hill-Sachs lesion demonstrated by the cortical depression seen at the posterolateral aspect of the humeral head. The mechanism which leads to a shoulder dislocation is typically traumatic which is represented by this patient's history. The patient also feels that his shoulder will "give out" and experiences painful motion in abduction and external rotation which is also indicative of an injury caused by an anterior dislocation. The patient also presents with an AC sprain (grade III) demonstrated by the elevated clavicle (another reason he is experiencing painful ROM). This type of injury may or may not require surgical intervention. Conservative treatment is the way to go. Modalities to decrease pain and inflammation, PROM/AAROM/AROM in pain-free limits, gentle mobs to help reduce pain, gentle scapular strengthening and PNF techniques to help restore the patient's proprioception.
ReplyDeleteThe view presented is an AP internal rotation view of the Right shoulder. I agree with most other posters that the diagnosis I see is a Hill-Sachs lesion secondary to a glenohumeral dislocation. The reasoning behind my diagnosis is a visible defect in the humeral head which is the hallmark sign of a Hill-Sachs lesion. Several posters have also identified an AC Joint sprain, but in my very limited experience of viewing radiographs have seen several shoulder views with an elevated clavicle on patients without any AC symptoms. Therefore, I do not believe the patient suffered an AC joint sprain. Initially, treatment should avoid any active motions into ABD or ER and should mainly be focused on pain management and edema control with electrical modalities and cryotherapy. Scapular, elbow,wrist and finger strengthening and AROM exercises should be initiated to help maintain strength proximal and distal to the shoulder joint. Initially I would err on the side of caution using a conservative approach especially since the patient presents with a very unstable shoulder joint that may be possible subluxing or giving the sensation to the patient.
ReplyDeleteThis view looks on first glance like an AP external view of the R shoulder due to what appears to be the greater tuberosity. And at times it looks like an AP internal view of the R shoulder due to what could be a Hill Sach's lesion. What is the best way to tell between the greater tuberosity and a possible "hatchet deformity"?? To me it appears to be an AP external view. I also believe this person has a bony bankart due to the radiolucent line at the anterior-inferior glenoid fossa. This would be caused by a dislocation, or a subluxation especially from trauma and is causing his feelings of instability. Also, a subluxation could have caused him to have a "stinger" or what he is reporting as a "dead" arm from the brachial plexus being stretched. This patient also appears to have had a mild to moderate AC sprain, indicated by the width at the AC joint. The patient should be treated very conservatively. You do not want him to have chronic instability from this point forward. Immobilization after a dislocation is necessary to allow the tissue to heal and the anterior capsule to tighten back up. At this time the pt should be treated with modalities to reduce pain and inflammation as well as elbow/hand AROM to increase blood flow to the distal arm. Progress slowly and avoid ER and Abduction initially of the shoulder after immobilization.
ReplyDeleteThis is an AP view with the GH joint in IR. Due to the pt history and the subsequent radiograph, I would suspect this pt suffered an anterior dislocation of the GH joint. I agree with many other posters that the main pathology that can be seen is a Hill-Sachs lesion on the posterolateral aspect of the humeral head, which is indicated by the hatchet deformity or depression. There is also a Bankhart fracture noted on the anteroinferior portion of the glenoid. I agree with David that the step deformity at the AC joint may not indicate an AC joint sprain due to lack of AC joint symptoms. This could also be an old injury. Therapy should consist of conservative management in the beginning in order to allow the anterior joint capsule and Hill-Sachs lesion to heal, including modalities for pain and edema management, light isometric strengthening of shoulder and scapular stabilizers. Active shoulder extension, abd, and ER should be avoided. As rehab progresses strenthening should include more active motions and progress to resisted active motions.
ReplyDeleteI agree that this is an AP IR view. With the MOI and appearance of the shoulder, I agree that there could be an AC sprain, but I would like to compare this view bilaterally and also with and without weights. I also agree that there is a Hill-Sachs lesion present and that also correlates with his MOI. I would initiate with conservative treatment with the goal of decreasing pain and maintaing ROM. Once pain decreases, it would be appropriate to progress treatment slowly and cautiously.
ReplyDeleteI agree with everyone thus far that this is an AP internal rotation view of the shoulder. The first thing I noticed in this image is the amount of space seen in the AC joint which may indicate a sprain or possible separation. Also there is a radiolucent part located on the inferior portion of the glenoid fossa which could also indicate a bankhart lesion. Considering the patients primary complaints, I believe he has anterior and inferior instability of the GH joint which could be due to a tear in the joint capsule. This patient should be treated conservatively for as long as possible unless his symptoms do not relieve in a reasonable amount of time. His shoulder should be immobilized to allow proper healing of the AC joint. In his first week, pain free PROM/AAROM(avoiding ER, extension, and full abduction) should be initiated along with gentle isometrics to maintain strength. Pain management as needed including cryotherapy can also be used in the first week. This patient should also be educated about guarding since he is reluctant that his shoulder will give out.
ReplyDeleteThis is an AP view of the R shoulder in IR. I agree with my classmates as I believe this patient has experienced an anterior dislocation resulting in a Hill-Sachs lesion, which agrees with his MOI and symptoms. The lesion is characterized by the hatchet deformity on the posterolateral humeral head. Looking at the anteroinferior glenoid, there is a fracture which usually accompanies a Hill-Sachs lesion. Since the clavicle is elevated in comparison to the acromion, one might suspect that he has suffered a AC joint sprain, but as David said, this might not be the case. The "dead arm" sensation is probably due to neuropraxia of the axillary nerve, since the MOI was traumatic. Since this patient is only 1 week out, therapy should focus on conservative treatment to allow proper healing, pain/edema management, light isometrics of the shoulder/scapula, and total arm strength and ROM. Positions to avoid: shoulder ER, extension, and abduction.
ReplyDeleteI agree with most of my classmates that this is an AP internal rotation view of the right shoulder. The primary pathology that I see is the Hill-Sachs lesion resulting from anterior humeral dislocation of the shoulder. This diagnosis fits with the pts MOI as a dislocation is often the result of a high impact play. This is evident by the hatchet deformity (compression deformity) shown on the posterior-lateral aspect of the humeral head. This is caused by the impact of the angular surface of the inferior glenoid rim during dislocation. Another possible pathology is a Bankart fracture noted on the anterior-inferior portion of the glenoid. One week out this patient should be treated conservatively, dislocation injuries are initially immobilized and modalities should be performed to decrease pain and inflammation and promote healing. Gentle isometrics may be innitiated as long as active abduction and ER are avoided. Some elbow/wrist AROM may be initiated to increase blood flow to tissue for healing.
ReplyDeleteI agree with the majority that this is a AP internal rotation view of the right shoulder, partly due to the "R INT-Rotate" located on the upper left portion of the image. I also agree with most in the diagnosis of a Hill-Sachs lesion due to the MOI and presence of a hatchet deformity. As far as the elevated clavicle goes I do believe there has been a AC joint sprain but am with Sarah W. and would like to see a comparison to the L before making a final call. I would definitely begin with conservative treatment of modalities for pain as well as pain free PROM/AROM avoiding ER and abduction at this time. I also think Melissa brought up a very good point about guarding education since he is having the feeling of his shoulder giving out.
ReplyDeleteI agree with my classmates so far that this is an AP internal rotation view of the right shoulder. There does appear to be slight separation of the AC joint, but agree that radiographs would need to be compared bilaterally with and without weights to determine AC instability. There also appears to be a Hill-Sachs lesion on the humeral head due to anterior dislocation. This is consistent with the traumatic injury and neuropraxia of the axillary nerve. Because of the anterior/inferior dislocation, the patient feels that the shoulder is unstable and painful during ER and abdcuction. These positions should definitely be avoided in and out of therapy. Therapy should begin conservatively with pain management modalities, PROM, AAROM, and some isometric strengthening of the shoulder and scapular muscles. Later, AROM and strengthening can be initiated in his pain free range.
ReplyDeleteI would agree with most of my classmates that this is an AP IR view of the R shoulder. The MOI and symptoms are consistant with an anterior/inferior dislocation of the humeral head resulting in a Hill-Sachs lesion, which commonly result from a traumatic injury. The Hill-Sachs lesion is noted by the posteriolateral indentation of the humeral head. The AC joint appears malalligned indicating a possible sprain, but this should be compared bilaterally, with and without weights, to determine the grade of sprain. The dead arm may be results of neuropraxia of the alillary nerve. The pt. complains of pain with ER and ABD motions and instability because of the anterior/inferior dislocation. Therapy should remain conservative to allow damaged tissues to heal, modalities for pain management, PROM/AAROM of the shoulder all with in the pain free range, strengthening of the scapular stabilizers,isometric strengthening of the shoulder, wands, pulleys, elbow ROM. AROM of the shoulder, strengthening and PNF patterns to begin later as long as activities are not painful.
ReplyDeleteLooking at this image I would agree with my classmates that have stated prior that this is an AP IR view of the R shoulder. Again, as classmates have stated, it appears that there is a dislocation resulting in the diagnosis of Hill-Sachs lesion. I feel that there is an abnormality of the AC joint, but would compare images bilaterally to see if that is a true problematic area. Due to the fact that he is just a week out, I would focus on reducing pain and inflammation/damaged tissues allowing healing time to occur. I would also begin isometrics of the shoulder to begin to strengthen an obviously loose capsule and weak musculature. I would also begin strengthening scapular stabilizers. Depending on the pathology of the AC joint, I would work in a painfree ROM and begin strengthening through that range as appropriate.
ReplyDeleteI believe this is an AP external rotation projection. Yes, I realize it says IR at the top; however, I can only see what appears to be the greater tuberosity, and not the lesser tuberosity which you would need to see to make it an internal rotation view. Though really, I could go either way on this. There is an increased space in the glenohumeral joint leading to a diagnosis of a Hill-Sachs lesion as correlates with the patient history. This would make me think AP internal rotation projection because this lesion is best viewed here. An AC sprain is also visible as noted with the relationship between the acromion and distal clavicle. Is it possible that it is an IR view, but because of the dislocation, the humerus shifted and it appears to be in slight ER? Rob, you got me on this one…
ReplyDeleteI would treat conservatively at this point. Therapy should focus on modalities for pain relief as well as PROM and AAROM. Abduction and ER should be avoided as they cause pain and guarding (Ok, class wins- probably wouldn’t do an AP ER radiograph for this reason!). Progression would include AROM and joint mobs, working on shoulder stabilization and strengthening.
I think everyone pretty much has this covered in stating that it is an AP IR view of a R shoulder. I also concur with my classmates who have stated that the image shows what appears to be a Hill-Sachs lesion probably resulting from a GH dislocation which would also make a Bankart lesion a possibility. The main indicator of this Hill-Sachs lesion is the hatchet deformity on the posterio-lateral humeral head. This diagnosis would also appear to make sense based on the MOI. It would also appear that there is a AC sprain, but having the contra-lateral shoulder to examine and compare would be helpful.
ReplyDeleteTreatment at this point should be conservative and focus on pain management (modalities/ joint mobs) and gentle passive ROM. Progression should be towards joint mobs for motion and AROM and then to light strengthening.
We are looking at an AP view of the right shoulder. I agree with some of my classmates in that it looks like this patient has an AC joint separation, but I believe that the patient may have a fracture of the glenoid inferior and medial to the humeral head. This fracture can occur due to anterior dislocation of the humeral head, which according to the patient description of his injury and symptoms, sounds like what happened. As for treatment: conservative care would be used since the patient is a week out, but is also dependent on the extent of damage. Appropriate treatments would be pain/edema control and elbow/hand/wrist exercises. If the shoulder needed to be immobilized, afterward you could begin the patient with gentle AROM/AAROM, gentle isometrics and shoulder stabilization exercises progressing to short range exercises (while limiting shoulder ER/abduction/extension ranges). Also, you should educate the patient on provocative positions for the shoulder and ways he can modify activities if needed.
ReplyDeleteSchmidt here...
ReplyDeleteAlso in agreement with previous posts, this AP IR view of R shoulder demonstrates likely Hill-Sachs lesion. H-S deformity secondary to suspected anterior humeral dislocation fits with arm tackle MOI and current pain with ER and abduction movements. Noting the AC position here, I agree that a contralateral comparison may offer additional information since s/s don't necessarily fit AC pathology. 'Giving out' ssn may be attributed to anteroinferior Bankhart lesion and associated anteroinferior instability. Possible coracoid fracture may be more clearly visualized w/ axillary view image. In addition to pain management and edema control, conservative treatment with UE weight supported easy isometric stabilization to tolerance, AAROM/PROM and AROM to tolerance. Active exercise and ROM elbow and wrist/hand indicated to preserve normal function.
I agree that this is an AP IR view of the R shoulder. Also, given the MOI, I agree that there was an anterior-inferior dislocation of the GH joint that has been reduced. There is the commonly associated glenoid fracture/bankart lesion at the inferior glenoid, however, I am not convinced that there is a Hill-Sachs lesion. Could it be possible that the arm is not fully IR'ed and maybe only slightly IR'ed past neutral and that is just the greater tubercle? It seems as though the humeral head is resting superiorly in relation to the glenoid fossa, possibly due to the trauma to the already weak inferior capsule. I think I see a discontinuity in the circumference of the coracoid process, possibly indicating a fracture of the coracoid process?
ReplyDeleteGiven the traumatic MOI, the dislocation should be treated with immobilization for a period of time in order to allow for tissue healing. At the one week mark, he should still be in a sling. Immobilization should be followed by PROM/AAROM and then rotator cuff and scapular strengthening.
I believe as others have mentioned that this appears to be a AP IR view of the R shoulder. The pathology present appears to be the presence of both Hill Sachs lesion as evidenced by a divot at the superior aspect of the humerus where the impact of anterior dislocation caused the articular surface of the humerus to be forced onto the glenoid. Additionally there appears to be a bankart lesion at the anterior aspect of the inferior rim of the glenoid demonstrating the separation of cartilage at the labrum. Since this injury is only a week out I would treat this conservatively as the patient may be immobilized for a period of several weeks to allow healing and promote stability. The patient may also be on activity modification as well to avoid future dislocations if possible. PT could consist of treating pain/inflammation with modalities, maintaining strength in the elbow/wrist/hand as well as re-establishing range and strength in the scapular and rotator cuff without aggression because depending on the age of the individual the liklihood of dislocation seems to increase the younger the age of the individual.
ReplyDeleteThe view is AP with IR of the R shoulder. I would say there is a slight AC joint sprain, but like most people have pointed out, there is also a hill-sachs lesion likely due to a dislocation of the shoulder. PT should be conservative early on to allow for optimal healing. Modalities, light strengthening, edema control, while avoiding active shoulder ER.
ReplyDeleteThis appears to be an AP IR view of the R shoulder. I believe there is a hill-sachs lesion in which there is a compression fracture of the humeral head from coming up against the anterior inferior glenoid. Also appears to be a bankart lesion which both are common with a shoulder dislocation. I also noted an AC sprain which seems to be type 2 or 3. Conservative rehab is indicated for him being only 1 week out due to increased risk for dislocation to reoccur. Therapy would include protection with use of sling, decreasing pain and inflammation using modalities, exercising elbow, wrist and hand, pendulum exercises and scap stabilization. Avoid abduction and ER.
ReplyDeleteWow you guys are getting pretty good!
ReplyDeleteLook closely at the inferior portion of the glenoid and you will see a small fleck of bone that has come loose. It is a bony Bankart fracture due to anterior inferior glenohumeral dislocation. You are also right in that there is a probably Hill-Sachs lesion.
Immediate conservative treatment would be immobilization for several weeks (approximately 3 pending physician protocol). More than likely this individual would have surgery soon to reattach fracture and capsule tissue. Standard Bankart protocol would follow. With surgery early following a bony Bankart these individuals tend to be stiff.