09-02 The Shoulder and Shoulder Girdle

Question 1

Synovial Joints

Answer 1

• Glenohumeral joints
• Acromioclavicular joints
• Sternoclavicular joints

Question 2

Glenohumeral joints

Answer 2

• Flex/Ext, ABD/ADD, IR/ER
• Arthrokinematics: Vex on Cave
• Stability: Rotator Cuff, Deltoids, Ligaments

Question 3

Acromioclavicular joints

Answer 3

• UR, DR, Winging, Anterior tipping
• Arthrokinematics: Cave on Vex
• Stability: Ac joint ligament, coracoclavicular ligaments

Question 4

Sternoclavicular joints

Answer 4

• PRO/RET (Cave on Vex), EL, DP (Vex on Cave)
• Arthrokinematics: Cave on Vex
• Stability: SC Ligaments, IC ligaments, CC ligaments

Question 5

Motions of scapula

Answer 5

• UR/DR, PRO/RET, Ant tilt, Winging

Question 6

Scapular Stability

Answer 6

• Sup angle = T2, Spine = T3, Inf angle = T7
• Active arm motions
• Faulty posture can impinge and limit movement

Question 7

Subacromial/Subhumeral space

Answer 7

• Overlay by Coracoacromial arch

- Contains subacromial bursa, supraspinatus tendon

Question 8

Scapulothoracic Rhythm

Answer 8

• 2:1 ratio
• 2˚ of glenohumeral movement for every 1˚ of scapular rotation
• Must have ER of humerus for full elevation [or greater tubercle jams into acromion

Question 9

Referred Pain and Nerve Injury

Answer 9

• Cervical Spine C4-C5 nerve roots
• Related tissues/organs: diaphragm, gallbladder, heart, liver to R shoulder
  Nerve disorders in shoulder girdle region: BP in thoracic outlet, suprascapular nerve in suprascapular notch [supraspinatus + infraspinatus] Radial nerve in axilla

Question 10

Glenohumeral joint - Pathologies

Answer 10

• Rheumatoid arthritis and osteoarthritis
• Traumatic arthritis
• Post immobilization arthritis or stiff shoulder
• Idiopathic frozen shoulder

Question 11

Maximum Protection Phase

Answer 11

• Acute phase
• Allows healing to occur without overstressing involved structures
• Pain free PROM, grade I and II mobs to decrease pain and promote jt nutrition; May be able to try submax mm setting; ice or other pain-inflammation reduction

Question 12

Moderate Protection Phase

Answer 12

• Stretch capsule
• Restive motion
• Address muscle imbalances
• Begin AAROM to AROM, progress to grades III and IV mobs if needed for jt play not yet restored; protect healing tissue for ROM and strength; work toward moderate function

Question 13

MInimum Protection

Answer 13

• Return to function
• Continue jt mobs if play/ROM still impaired, progress to strengthening for remaining deficits and progress activites to restore negative function

Question 14

Capsular Pattern - Shoulder

Answer 14

• ER - ABD - IR

- Equals capsular pattern, but if not in pattern, may be joint stiffness

Question 15

Adhesive Capsulitis Stages

Answer 15

• Unknown cause; Inflamed capsule
• More prevelant in females
• More prevalent ages 40-60, menopause, diabetes 2nd to OA/RA
• Stage 1: Acute (Chilling) - < 3 mths; P with Movement
• Stage 2: Freezing - 3-9 months; P with movement, at rest
• Stage 3: Frozen 9-15 months: P with movement, but decreased
• Stage 4: Thawing - 15-24 months: Minimal pain, just stiffness; Return to motion

Question 16

Adhesive Capsulitis Motions

Answer 16

• Stage 1: No significant movement, maybe ER
• Stage 2: All directions, ER - ABD - IR (Lose capsular pattern)
• Stage 3: Very little movement, capsule stuck, glide limited
• Stage 4: Mild-moderate limitations, Partial return of motion

Question 17

Required Dx for Frozen Shoulder (4)

Answer 17

• Loss of capsular pattern with AROM: ER - ABD - IR
• Loss of capsular pattern with PROM: Restricted in both AROM and PROM
• Loss of capsular pattern with accessory muscles (glides): ANT - INF - POST
• Loss of capsular pattern with end feels: Leathery
• Must have all four to take into full eccentric control; If not loss of all four, shoulder is merely stiff, imited

Question 18

Joint Hypomobility

Answer 18

• Clinical S&S: Pain, LOM, substitution, pain at ACSC joints
• Structural/Functional impairments: LOM of GH, AC/SC joints; lose ST rhythm, muscle weakness, muscle length, balance
• Limitations/Restrictions: Elevation; reaching out to side/back [Ex: Drive-Thrus, ATMs]; difficulty getting dressed; cleaning; eating, etc.

Question 19

Joint Hypomobility - Protection Phase

Answer 19

• Acute: Careful not to crank and cause pain
• Stage 1-2 of adh. cap.
• Maintain soft tissue and joint integrity and mobility: PROM of involved jts, Grade I and II mobs, mm setting ex [Codman’s Pendulum]
• Maintain integrity and function of associated regions [ cervical, thoracic, elbow, hand, etc.]

Question 20

Joint Hypomobility - Controlled Motion Phase

Answer 20

• Subacute
• Stage 2-3 of adh. cap.
• Control pain, edema, joint effusion
• Progressively increase joint/soft tissue mobility: add AROM in pain free ROM, grades III & IV mobs, stretching
• Inhibit muscle spasm and correct faulty mechanics
• Improve jt tracking
• Improve muscle performance
• Postural Re-education: Cervical retraction, thoracic spine extension
• Use modalities if necessary

Question 21

Joint Hypomobility - Return to function phase

Answer 21

• Progressively increase flexibility and strength: Restore mm balance, postural and mm re-ed,, jt mobs more aggressive if still needed
• Progress from earlier simple exercises to more complex actions and simulate functional tasks; body mechanics
• HEP training: both what ex and why to improve compliance