2 - Shoulder Flashcards
Give at least (3) indications of an inferior humerus?
(1.) Shoulder visualizes as being low with soft tissue dimpling/ sulcus sign.
(2.) Point tenderness at the anterior aspect of the G-H joint.
(3.) Loss of fluid motion.
(4.) Loss of Appley’s external rotation.
(5.) Anterior deltoid weakness.
Indications of a posterior humerus?
- visualizes normally, no apparent visual change.
- lost fluid motion
- point tenderness at posterior aspect of G-H joint
- Loss of internal rotation
- Teres major muscle weakness
With any shoulder complaint the Dr. should routinely examine? `
- St-Cl,
- A-C,
- G-H,
- Sc-Th,
- St-Co,
- & definitely the spine for subluxation.
On Scapulo-Thoracic Lateral (S-T L) what position do we place the patient’s arm?
-Behind the pts. back (side lying) with doctor reaching through the pts. axillary/ arm opening.
Where is #11 of the stabilization hand? S-T L
-Over the A-C joint
Where are the fingers?
S-T L
-Over the G-H joint
In what direction does the stabilization hand push to bring the joint to tension?
S-T L
-S to I
What’s the pain point for S-T L?
-Deep to or under the scapula, in the subscapularis muscle.
How to differentiate S-T L (lateral) from S-T M (scapulo-thoracic medial)?
1.) Fluid motion,
2.) -visualization of distance from spine
3.) S-T L = (lateral) Appley’s scratch in internal rotation is diminished
4.) S-T M = (medial) Appley’s scratch in external rotation is diminished.
What part of the scapulo-humeral ratio would be decreased with a G-H P?
-The Glenohumeral portion.
Scapulothoracic medial, prone: Three most common mistakes for this:
1.)-Should have patient’s shoulder off the table
2.)-Should have Dr. stand on opposite side of contact
3.)-Should use inferior hand contact
G-H posterior, prone-LOC?
-P-A, be careful to not get any S-I
Where is the patient’s shoulder?
-Supported on the table
Why is the shoulder on the table?
-For stabilization; we don’t want to dislocate it
Indication of Yergason’s positive?
- Bicepetal tendon instability, usually caused by a shallow groove
- or a tear or sprain of transverse humeral ligament
Drop Arm test: describe 3 parts least-to-most invasive and diagnosis for each
1.) Pt. lowers arm to side against gravity; if it drops fast, it’s often a severe tear of rotator cuff,
grade 3. Supraspinatus muscle.
2) Apply a little pressure while they lower it; some resistance, moderate tear of rotator cuff, grade 2
3) Put an impulse in the abducted arm; fair resistance, mild tear or strain of rotator cuff, grade 1
G-H P, seated: What is most important about LOC?
-Straight P-A, drop elbow so it’s level or below the wrist
What ROM’ s do you use to bring it to tension?
G-H P
-Abduction & extension
Where is the pain point?
G-H P
-Over the posterior glenohumeral joint
How to differentially diagnose a G-HP, from a G-H Inf.?
- Pain point is posterior; visualizes as normal, not inferior.
- G-HP is decreased ROM on internal rotation, not external rotation
(Appley’s Scratch ROM loss on internal rotation, not external).
- X-ray shows humeral head is posterior and superior, not inferior
- Teres major muscle test is weak on G-H P, not the anterior deltoid as G-H I.
Is this the move of choice?
G-H I
No
Supine traction. Because you can feel the joint.
What are at least three other alternatives to differentiate this diagnosis from?
G-H I
- G-H posterior, Subacromial bursitis, bicipetal tendonitis,
- bicipetal instability, sprain or tear of rotator cuff,
- dislocation, heart attack, gall bladder, spleen
Describe the 3 parts as you’re doing them
Frozen Shoulder
1) traction, release; if ROM is gained, go on to part 2
2) traction through ROM gained, back to neutral, release
3) after a few visits if no part 2 progress, traction and take it through the ROM gained, at end-ROM put an impulse down the shaft of the humerus, bring it back to neutral, return to part 2 until no more progress. Post check with ROM and comparing L side to R side.
G-H traction, seated: Dr’s arm in Pt’s. armpit with thumb up.
What are your limiting factors?
- Patient tolerance & visualizing the joint space to open up.
- (Note: it is important to be visualizing this during the practical)
-Is this the move of choice for a G-H fixation?
G-H Traction supine
-Yes, because you can palpate the joint space rather than just visualize it.
Give at least “3” diagnoses that G-H traction, supine would work for?
- Frozen shoulder,
- inferior humerus,
- posterior humerus,
- osteoarthritis with fixation,
- G-H dislocation.
How do you bring this joint to tension before the thrust? + Describe the thrust
St-Cl Superior
- Bring the arm into abduction & extension.
- Straight S-I, maybe a little torque, fingers point toward the axilla
What are we doing with our opposite arm?
St-Cl traction seated
-Holding the opposite shoulder back
Why do we hold the shoulder back?
St-Cl traction seated
-Isolating the st-cl joint, not rotating the thoracics
What direction does the clavicle most commonly subluxate
St-Cl traction supine
Superipr
Is this traction move a post-check for St-cl Superior?
St-Cl Traction supine
-NO, this is actually a procedure & should be done before St-Cl S
Which part of this takes care of superiority?
A-C PS
-Pushing down on the distal end of the clavicle
Which part takes care of the posteriority?
A-C PS
-Pushing slightly forward and externally rotating the arm.
Most common muscle involved with Hyperabduction Syndrome or a positive Wright’s?
-Pectoralis minor
What causes the pectoralis minor to be shortened or go into contracture?
(1.) Cervical subluxation,
(2.) subacromial bursitis,
(3.) rolled shoulder posture
(4.) other types of TOS
Scalenus anticus syndrome is caused by what?
-subluxation usually
What to do for scalenus anticus syndrome?
-Adjust subluxation,…. then use moist heat to relax the muscles,….finally stretch
Positive Eden’s indicates?
- Decreased pulse volume or amplitude (not rate),
- TOS,….Costoclavicular syndrome
How to treat for positive Eden’s?
- Find out if it’s muscle guarding often indicating a hypertonic pectoralis major involvement, which needs to be stretched out.
- It may also be a cervical, thoracic or rib subluxation, often helped by adjusting.
What questions might you ask if a patient has a positive Eden’s?
-Do they carry a backpack?….Do they carry heavy objects in front of them at work?
-Ever had accident with the seatbelt on?…Ever had a fractured or dislocated clavicle,…or shoulder problem?
-Have they ever _f_allen _o_n their shoulder or with an _o_ut stretched arm/hand (FOOSH) ?
How far up and back do we go with the patient’s shoulder?
St-Co traction seated
-To patient tolerance or until you feel the joint open up
How far up and back would you go for rib 2 compared to rib 5?
St-Co traction seated
-Not as far, it won’t take as much rotation/extension for rib 2
Where is the pain point for this?
St-Co traction seated
? -Pain right over the joint space.
-(Superior rib) located over the top of rib head. –(Inferior rib) located over bottom of rib head
What is the best way to post check?
St-Co traction seated
-Have the patient take a very deep breath in while bringing shoulders up, then blow it all the way out while feeling the excursion of the ribs involved.
St-Co S*** or ***St-Co I
Which rib levels may commonly need St-Co thrusting type adjusting procedures?
-Ribs 2 – 5.
What’s patient placement?
St-Co S*** or ***St-Co I
-Supine, on the center of the table
Doctor’s stance?
St-Co S*** or ***St-Co I
-Straightaway so that you don’t have body drop
What type of breathing would show aberrant motion with a St-Co S?
-On expiration, the rib doesn’t come down
Where is the pain point?
St-Co S
-Right over the sternocostal joint of the involved rib
What if the pain is running along the rib all the way around?
(1.) Probably subluxation of the thoracic spine;
(2.) shingles,
(3.) intercostal neuralgia,
(4.) fracture,
(5.) Tumor,
(6.) Heart Attack if on the left
What do you do for patient safety on St-Co S?
-Turn their face away so you don’t put your elbow in it,
What do you do to get an S-I, LOC?
-Drop your elbow down close to the chest wall
What breathing instructions do you give the patient on a St-Co S
-Blow air all the way out and hold
Why do you give the breathing instructions?
St-Co S
- “blow out” air so that musculature is pulling down on rib & opens up the joint space underneath the rib
- “hold” to keep from forcing out residual air
Breathing instructions?
St-Co I
-Take a deep breath in and hold
What’s the best post-check?
St-Co I
-Fluid motion
How would you do fluid motion on St – Co I .
-Put fingers above and below rib you’re testing, breath in and out
Which should you see improvement on, inspiration or expiration?
St-Co I
-Inspiration
When not to use mentholated rubs?
- Allergies,
- Pneumonia,
- they are oil-based & will leave residue in lungs.
Patient placement
St-Co Traction supine
-Supine, shoulder way off the table, especially for lower ribs
Which way should Dr.’s fingers point?
St-Co traction supine
-M-L, some (S-I) or ribs 2-3rd or (I-S) 4-5th to follow the involved rib attitude depending on how low in the rib cage you are.
What is the limiting factor for bringing arm up and back?
St-Co traction supine
-Patient tolerance or until you feel the joint open
Visualization Steroclavicular joint
-superior clavicle: compare proximal ends of the clavicles to see if one sits higher than the other
Visualization AC
- posterior superior clavicle: one distal end of clavicle sits higher than the other.
- Compare trapezius muscles on each side to see if there is a smooth transition over the distal clavicle. (Step sign.)
Visualization GH
-inferior humerus: roundness of one shoulder is sitting lower in relation to the acromion process (dimpling) (Sulcus sign).
Visualization: Scapulothoracic
-lateral/medial scapula: vertebral border of scapula has flared laterally/medially w/ respect to midline (spine)
Most common shoulder misalignment?
-G-H I (Inferior, due to gravity)
Most common shoulder dislocation? Why?
- Anterior-inferior;
- gravity pulls it down & forward,
- carrying things pulls it down & forward
- the anterior glenoid labrum is shallow
What tests will help differentially diagnosis (ddx) an inferior & posterior humerus?
- Yergason’s,
- Dawburn’s,
- Supraspinatus
Extra information use: (Appley’s Scratch & Teres Major for internal / external ROM )
Kocher’s Maneuver:
-Traction,.…external rotation,…adduction,…internal rotation,.…finalize support as in Dugas
What three systems do you want to check on your post check?
Kocher’s Maneuver
Neuro
Vascular
Musculoskeletal
Why do a 3-part procedure vs. surgery for frozen shoulder (Adhesive Capsulitis)
-Less risk of fractured humerus, dislocated glenohumeral joint
Most important component of frozen shoulder treatment?
-Find out what caused them to stop using their shoulder allowing it to “freeze”, then address the problem. Could be due to scar tissue buildup, or DJD / Arthritis.
Most common _AC misalignmen_t
-posterior superior.
What is “shoulder separation”?
-dislocation (vs. subluxation) of AC joint
ROM vs. immobilization for AC joint?
- Subluxation w/fixation……-do ROM, not immobilize
- Dislocation ……-immobilize with brace or “reminder” tether
*“Move of choice” for G-H joint?
-traction with patient supine because you can palpate the joint during this procedure.
