2: GH Joint Flashcards
What joints and articulations make up the shoulder complex?
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic articulation
What is the origin of Teres major?
Inferior angle of scapula and inferior 1/3 of the lateral border
What is the origin of teres minor?
Middle 1/3 of lateral border of scapula
During all movements, the humerus obeys the ____
Convex rule
What is the convex rule?
Roll and glide are in opposite directions
What is the open-packed position for the glenohumeral joint?
55 degrees of ABduction in the scapular plane
Where is the scapular plane?
30 degrees anterior to the coronal plane
What is the close-packed position for the glenohumeral joint?
Full ABduction and external rotation
A low grade mobilization stretches the tissue (TRUE/FALSE)?
FALSE
A low grade mobilization is used when ____ is the dominant symptom?
Pain
A high grade mobilization stretches tissues (TRUE/FALSE)?
TRUE
A high grade mobilization is used when ____ is the dominant symptom?
Stiffness or joint restriction
High grade mobilizations can involve oscillations and small amplitude thrusts (TRUE/FALSE)?
TRUE
What are the most common causes of mechanical shoulder pain in the office?
GH joint disorders
Rotator cuff disorders
AC joint disorders
GHJ instability
Impingement syndrome involves a ____ muscle?
Rotator cuff
A distraction is an example of a (Low/High) grade mobilization in the (Closed/Open) packed position?
Low, Open
A glide or rotation is an example of a (Low/High) grade mobilization that is (More/Less) aggressive?
High, More
What is osteoarthritis?
A progressive non-inflammatory disease characterized by degenerative pathological changes in the articular cartilage and its related components
Osteoarthritis is inflammatory (TRUE/FALSE)?
FALSE
Male patient age 62 presents with shoulder pain that has been progressively getting worse over the past year and a half. The pain is a 3/10 at rest but becomes a 6/10 during activity. Physical exam reveals decreased active and passive ROM in the GH joint in all planes as well as crackling sounds when the GH joint is mobilized. What is a likely working diagnosis?
Osteoarthritis of the GHJ
Osteoarthritis of the GH joint presents with decreased ____ and ____ ROM?
Active, passive
How will osteoarthritis present on a radiograph?
Decreased joint space
Subchondral sclerosis
Osteophyte formation
What conservative treatment can be done for osteoarthritis of the GH joint?
Mobilization or manipulation
Ice or heat
Passive stretching
Strengthening of muscles
(Distraction/Glide) techniques are often better tolerated in patients with OA of the GH joint?
Distraction
What is adhesive capsulitis commonly known as?
Frozen shoulder
What is adhesive capsulitis?
A chronic disorder of the GH joint capsule and synovial lining in which an initial inflammatory process is followed by reactive joint capsule fibrosis
Primary adhesive capsulitis arises spontaneously and is not associated with or caused by a previous disease (TRUE/FALSE)?
TRUE
Secondary adhesive capsulitis is associated with an earlier disease or disorder (TRUE/FALSE)?
TRUE
What is the most common cause of secondary adhesive capsulitis?
Systemic disorders
What systemic disorders can cause adhesive capsulitis?
Diabetes mellitus (10-36%)
Thyroid disease
Autoimmune disease
What shoulder disorders can cause adhesive capsulitis?
Rotator cuff disease
Prolonged shoulder immobilization
Shoulder trauma
What non-shoulder disorders can cause adhesive capsulitis?
Chest or breast surgery
Myocardial infarction
Non-shoulder surgery
How old is a typical patient with adhesive capsulitis?
40-60
Stage one of adhesive capsulitis is painful (TRUE/FALSE)?
TRUE
Stage one of adhesive capsulitis is characterized by inflammation of the ____
Synovial lining
In what stage is adhesive capsulitis most commonly misdiagnosed?
Stage one
What is stage two of adhesive capsulitis?
Frozen stage resulting in fibrosis and contracture of the joint capsule with stiffness
Stage two of adhesive capsulitis is characterized by joint capsule ____ and ____
Fibrosis, contracture
Stage two of adhesive capsulitis is the pain stage (TRUE/FALSE)?
FALSE
What motion is most restricted first in stage two of adhesive capsulitis?
External rotation
What is the ROM loss pattern in adhesive capsulitis?
EXT ——> ABduction ——> INT
What is stage three of adhesive capsulitis?
Thawing stage where the joint capsule gradually remodels and stretches
Stage three of adhesive capsulitis is characterized by ____ and ____
Remodeling, stretching
A radiograph of a patient with adhesive capsulitis will be unremarkable (TRUE/FALSE)?
TRUE
In what stages of adhesive capsulitis is the chiropractor most effective?
Stages two and three
A CT or MRI in stage one of adhesive capsulitis may show what?
Inflammation and edema
A CT or MRI in stage two or three of adhesive capsulitis may show what?
Thickened joint capsule
What treatment can be provided during stage one of adhesive capsulitis?
Low grade mobilization, Codman’s pendulum exercises and TENS unit
Which type of mobilization is best for treating stage 2 adhesive capsulitis?
Low grade
What motion is lost primarily in adhesive capsulitis and lost first?
External rotation
What are the two main functions of the rotator cuff muscles?
Rotation of the humerus and stabilization of the glenohumeral joint
How do the rotator cuff muscles rotate the humerus?
Contraction of individual RC muscles or force coupling in opposite reactions
What is the action of supraspinatus?
Abduction of the arm
What is the action of subscapularis?
Internal rotation of the humerus
What is the action of infraspinatus and teres minor?
External rotation of the humerus
What muscles aid in flexion and abduction through force coupling in the shoulder?
Infraspinatus, teres minor, subscapularis, and the deltoid
What is a force couple?
Two forces of equal magnitude acting in opposite directions to rotate a body around its axis of motion
What muscle group is the most important stabilizer of the glenohumeral joint in the mid-ranges of motion?
Rotator cuff muscles
Through what mechanism does the rotator cuff complex stabilize the glenohumeral joint?
Concavity compression stability mechanism
A shallow glenoid fossa with a small concavity would need (Weak/Strong) compression by the rotator cuff to maintain joint stability?
Strong
A deep glenoid fossa with a large concavity would need (Weak/Strong) compression by the rotator cuff to maintain joint stability?
Weak
What is the most commonly dislocated joint in the body?
Glenohumeral joint
What is the most common cause of shoulder pain in patients over 35?
Rotator cuff disorders
What is tendinopathy?
A broad term used to describe any pathology involving a tendon and is inclusive of several different tendon pathologies including tendinitis, tendinosis, and tenosynovitis
Tendinosis is (Inflammatory/Non-inflammatory)?
Non-inflammatory
What is tendinitis?
An inflammatory condition of a tendon
What is tendinosis?
A non-inflammatory degenerative change in a tendon commonly due to aging, micro trauma, vascular compromise, or failed healing
Tendinitis is (Inflammatory/Non-inflammatory)?
Inflammatory
What is tenosynovitis?
Inflammation of the synovial sheath that surrounds some tendons
What is the number one tendon injured in a rotator cuff tendinopathy?
Supraspinatus tendon
Rotator cuff tendinopathy usually affects what age group?
Patients over 35
Patients under 35 years old with rotator cuff tendinopathy are mostly ________________?
Athletes
What are the major causes of rotator cuff tendinopathy?
Major trauma
Age-related degeneration
Tension overload
Impingement
What is a FOOSH injury?
Fall on an outstretched hand
What is the likely cause of age-related rotator cuff tendon degeneration?
Poor vascular supply of the supraspinatus tendon in the critical zone
Age-related degeneration as a cause of rotator cuff tendinopathy is often asymptomatic (TRUE/FALSE)?
TRUE
Tension overload of the rotator cuff tendon is most commonly seen in what population?
Overhead athletes (baseball, football, throwing)
What is the most common cause of symptomatic rotator cuff tendinopathy?
Subacromial impingement
What is subacromial impingement?
Compression of the tissue in the subacromial space between the humeral head and the undersurface of the coracoacromial arch
What is the subacromial space?
Space between coracoacromial arch and humeral head
What forms the coracoacromial arch?
Anterior 1/3 of acromion
AC joint
Coracoacromial ligament
Coracoid process
When are tissues in the subacromial space NORMALLY compressed?
60 degrees shoulder abduction
What tissues are located in the subacromial space?
Subacromial bursa
Supraspinatus tendon
Long head of biceps tendon
What can cause narrowing of the subacromial space?
Functional narrowing
Structural narrowing
Swelling
What tissue is most commonly impinged in the subacromial space?
Subacromial bursa
What is the most common type of narrowing of subacromial impingement?
Functional narrowing of the SAS
What can cause functional narrowing of the subacromial space?
Strength imbalance between rotator cuff and deltoid
Tight GHJ POSTERIOR capsule
Tight GHJ INFERIOR capsule
Poor upward rotation of the scapula during elevation
How can a strength imbalance between the rotator cuff and deltoid be determined?
Absolute or relative weakness of the rotator cuff compared to the deltoid
If strength of the deltoid overwhelms the concavity-compression stability mechanism of the RC, the humerus is pulled ____ during flexion or abduction causing impingement?
Superior
A deltoid that is stronger than the rotator cuff will cause the humerus to pull ____
Superior
What is an absolute weakness of the rotator cuff muscle compared to the deltoid?
Rotator cuff is weak and the deltoid is strong
What is a relative weakness of the rotator cuff muscle compared to the deltoid?
Both muscles are strong but the deltoid is much stronger than the rotator cuff
How does a relative weakness of the rotator cuff compared to the deltoid occur?
Rotator cuff deconditioning, tendinopathy, or tear
A tight GHJ posterior capsule will pull the humerus ____ during flexion?
Anterior and superior
What vector would be used to correct a tight GHJ posterior capsule?
A—-P Glide
When asymmetric tightness of the capsule exists it causes abnormal translation of the humeral head away from the side of tightness (TRUE/FALSE)?
TRUE
A tight GHJ inferior capsule will pull the humerus ____ during shoulder abduction causing impingement?
Superior
What two factors determine the age of onset for a RC injury?
How often and how intense the rotator cuff muscles are worked
Decreased upward rotation of the scapula during ____ & ____ can cause functional narrowing of the SAS?
Flexion, abduction
What can cause structural narrowing of the SAS?
AC joint spur
Abnormal acromion shape
What can cause swelling in the SAS?
Tension overload (athletes with repetitive tearing and swelling)
Acute trauma (FOOSH)
A FOOSH injury will push the humerus ____
Superior
Where will pain present clinically in a patient with subacromial impingement?
Anterior/anterolateral shoulder pain
Where does pain often refer to in a patient with subacromial impingement?
Deltoid insertion
A patient with a subacromial impingement may have what history?
Athletics involving overhead sports (throwing, swimming, tennis, baseball)
Occupation involving overhead work
Older age (60+, if not as active)
A C5 radiculopathy will radiate to the (Medial/Lateral) arm?
Lateral
A C6 radiculopathy willl radiate to the (Medial/Lateral) forearm?
Lateral
What is a typical patient for subacromial impingement in terms of age?
Over 35
What is the major cause of a subacromial impingement?
Idiopathic (no precipitating event)
What is the diagnostic criteria for a subacromial impingement?
Functional or structure impingement combined with cumulative effects of repetitive impingement from overhead use
A patient with a single event causing subacromial impingement will have ____ in the SAS?
Swelling
What are possible areas of tenderness in a patient with a subacromial impingement?
AC joint
Anterolateral edge of acromion
Insertion of supraspinatus on greater tuberosity
Long head of biceps tendon
How is a supraspinatus strength test done?
Thumb up (full can) with the shoulder in 90 degrees of the scapular plane. Hold arms out and test muscle strength pushing downward
How is an infraspinatus or teres minor test done?
External rotation of the shoulder by bracing the hand and pushing on the arm and elbow to resist external rotation
How is a subscapularis test done?
Internal rotation test by pulling the arm into external rotation and having patient resist
OR
Lift-Off test: Have patient put hand behind back and apply some pressure P—-A
What muscles are internal rotators of the shoulder?
Subscapularis, pec major, latissimus dorsi, teres major
What are orthopedic tests for subacromial impingement?
Neer Test
Hawkins Test
Impingement Sign
How do orthopedic tests primarily produce subacromial impingement?
Holding the acromion down
What are the most common orthopedic tests for subacromial impingement?
Neer Test
Hawkins Test
How is a Neer test performed and what does it assess for?
Patient holds arm above head testing for subacromial impingement
How is a Hawkins test performed and what does it assess for?
Patients holds arm 90 degrees in front of them and the doctor pushes down on the hand and up on the elbow to lower the acromion testing for subacromial impingement
What is the supraspinatus press test?
Orthopedic test thumb down (empty can) for the supraspinatus
A supraspinatus press test is a (Full Can/Empty Can) orthopedic test?
Empty Can
A supraspinatus strength test is a (Full Can/Empty Can) strength test?
Full can
Which supraspinatus test is most likely to cause pain if an impingement is present?
Supraspinatus press test (Thumb down/empty can)
What GHJ mobilization techniques can be effective for treating subacromial impingement?
S-I glide and A-P glide
How should all shoulder mobilization techniques be performed?
Arm above 30 degrees abduction in the scapular plane to minimize stress
When should you refer out for a suspected subacromial impingement?
Severe pain (7/10 or difficulty sleeping)
Worsening pain, weakness, or dysfunction
No improvement after 4-6 weeks
Surgical treatment may be effective for ____ causes or swelling in the SAS but is NOT as effective for ____ causes of impingement?
Structural, functional
What is the most important method of GHJ stabilization by the RC muscles?
Compression of the humeral head into the glenoid fossa (C-C stability mechanism)
During 180 degrees of shoulder abduction and flexion how much does the humerus and scapula move?
Humerus moves 120 degrees and the scapula rotates upward 60 degrees
The four most common causes of functional narrowing of the subacromial space can all be effectively treated with ____
conservative care
