9/20 - Shoulder Exam Anatomy, Fx, OA, TSA Flashcards
1
Q
what is the significance of the sternoclavicular joint
A
only skeletal articulation to axial region
2
Q
describe the anatomy of the glenoid fossa
A
pear-shaped
- anteverted 30
- tipped superiorly
posterior portion of capsule is thin
3
Q
what are the passive structures associated w shoulder anatomy
A
bony surfaces
- humeral head
- glenoid
capsulolabral ligamentous complex
- A/P capsule
- anterior GH ligaments
- A/P labrum
4
Q
what are the active structures associated with shoulder anatomy
A
rotator cuff
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
long head of biceps
5
Q
what function does the long head of the biceps serve
A
position of ABD & ER
controls superior and anterior translation
6
Q
describe the biomechanics of scapulohumeral rhythm
A
2deg of GH motion for every
1deg of ST motion
180 shoulder elevation
- 120 humeral elevation
- 60 scapular rotation
7
Q
what are force couples associated w the shoulder
A
deltoid - rotator cuff (supra)
anterior - posterior rotator cuff
trap - serratus anterior
8
Q
if there is unopposed deltoid force, what is the result
A
superior migration
9
Q
what are the primary forces at the shoulder
A
deltoid / rotator cuff (supraspinatus)
10
Q
what is the rotator cuff’s primary job
A
keeping head of humerus centered in glenoid
11
Q
what do you usually see in someone with cuff pathology
A
compensatory shrug
12
Q
where does most cuff pathology start
A
at supraspinatus
13
Q
if have supraspinatus pathology, what does this mean for shoulder stabilization
A
will probably still be relatively stable due to anterior - posterior rotator cuff force couple
14
Q
pathology affecting what muscles will result in visible pronounced deficits
A
as damage extends and affects the AP force couple
15
Q
what muscles are involved in the anterior-posterior rotator cuff force couple
A
anterior - subscapularis
posterior - infraspinatus, teres minor
16
Q
what motions do the trap-serratus anterior force couple create/assist with
A
shoulder elevation
upward rotation of scapula
posterior tilt of scapula
17
Q
what are 4 functions of the trap-serratus anterior force couple
A
- optimal position of glenoid
- deltoid length - tension
- prevents impingement
- stable base to recruit scapular musculature
18
Q
how does the T-SA force couple relate to the deltoid
A
gives ideal length-tension for deltoid to work
19
Q
tissue amt in anterior GH vs posterior
A
tissue tends to be more robust anteriorly
- posterior GH is thin
20
Q
what are ligaments
A
thickenings of GH capsule
21
Q
what force couple is important for overhead functioning
A
trap - serratus anterior
22
Q
shoulder complaints not d/t traumas are often d/t
A
imbalances in T-SA force couples
23
Q
what is the significance of T-SA creating UR and posterior tilt of the scap
A
allows for clearance under coracoacromial arch to prevent impingement and normal overhead functioning
24
Q
where does impingement happen
A
between acromion and humerus
- lot of stuff lives there
25
what are 4 types of pain that can be associated with the shoulder
cervical referral (facet/disc)
visceral/vascular referral
subacromial structures & GH joint
AC joint
26
where will pain from subacromial structures and GH joint present
distal to acromion in lateral deltoid region
27
where will pain from AC joint present
top of acromion surrounding AC joint
28
sx at top of shoulder, sus of what
AC joint
29
sx at anterolateral shoulder, sus of what
RC
subacromial syndrome
30
how does RC pathology present
pain beneath acromion and lateral to deltoid region
31
what is a common location for arthritis
AC joint (top of shoulder)
32
what common shoulder paths have a overuse MOI
tendinopathy
atraumatic instability
33
what common shoulder paths have a trauma MOI
fx
RC tear
AC separation
GH sublux/dislocation
34
what are 7 things to ask about if someone is experiencing pain
1. MOI
2. aggravating factors
3. alleviating factors
4. 24 hour pattern
5. pain severity
6. pain irritability
7. chronicity
35
adhesive capsulitis (primary) sx (3)
persistent anterior-lateral shoulder pain
inability to sleep d/t pain
gradual loss of motion
- mostly ER limited
36
risk factors of adhesive capsulitis (primary) - 4
females
40-65yo
DM
hypothyroidism
37
GH OA (primary) sx - 2
gradual onset of pain & loss of motion
stiffness in morning
38
risk factor for GH OA (primary)
>60yo
39
AC joint arthropathy/injury sx - 3
pain at top of shoulder near AC
inc pain end range elevation and/or horizontal ADD
may have visual deformity
40
AC joint arthropathy/injury associated hx (2)
heavy weightlifting
contact trauma w inferior force
41
subacromial pain syndrome sx (4)
1. anterior-lateral shoulder pain
2. pain w motion at or above shoulder height
3. painful arc w active elevation
4. inc pain at night
42
what are 2 tests that can be done to r/i subacromial pain syndrome
(+) impingement signs
(+) LHBT tests
43
what pathology do you see a painful arc in other than subacromial pain syndrome
abnormal/injured trap-SA force couple
44
describe the painful arc seen w subacromial pain syndrome
as you raise your arm up (scap needs to rotate and posteriorly tilt to make more space) once you get to 60/70 through 110/120, will be painful
- that is where the mechanical impingement can happen
45
rotator cuff tear sx - 5
anterior lateral shoulder pain
limited strength
pain wakes during sleep
pain worse at night
(+) Lag signs
46
what is a risk factor for rotator cuff tears
40yo
47
what would a pt w GH OA (primary) c/o
crepitus or catching with end ROM
48
anterior instability or labral tear sx - 2
anterior shoulder pain
apprehension/pain end range ABD-ER
49
anterior instability or labral tear common hx (2)
ant-inferior trauma
recurrent sublux/dislocations
50
what would a pt w anterior instability or a labral tear c/o
clicking/clunking
locking
"dead arm syndrome"
51
is anterior or posterior instability more common
anterior
52
what pt population do you frequently see anterior instability in
throwers and overuse athletes
53
posterior instability sx
apprehension/pain in combined flexion and horizontal ADD w posterior force
54
posterior instability common hx
trauma w recurrent sublux/dislocations
- aka FOOSH
55
posterior instability c/o
pain w pushing/CKC activity
56
posterior internal impingement sx
posterior pain in late cocking phase (think pitcher)
- aka ABD-ER with horizontal plane hyper-ABD
dec performance
57
SLAP lesions sx
deep anterior pain w mechanical sx
pain w throwing or biceps loading
58
what does SLAP stand for
Superior Labrum from Anterior to Posterior tear
59
what is LHB
long head of biceps
60
LHB tendinopathy sx
anterior pain isolate to LHBT in groove w shoulder flex & arm supination
61
what are the stages of irritability
low
moderate
high
62
what does high irritability mean
pain >7/10
constant night or rest pain
constant sx
high disability level
63
what does moderate irritability mean
pain 4-6/10
intermittent pain
moderate disability level
64
what does low irritability mean
pain <3/10
no resting or night pain
low disability level
65
what are red flags that will probably require a referral out (7)
tumors
infection
visceral pathology
rheumatological conditions
polymyalgia rheumatica
nerve palsy
parsonage-turner syndrome
66
what is a risk factor for polymyalgia rheumatica
>60yo
67
what nerves do you typically see nerve palsy in that may refer pain to the shoulder
long thoracic
spinal accessory
68
what are overuse injuries (2)
tendinopathy
atraumatic instability
69
what are traumatic injuries (4)
fx
RC tear
AC joint separation
GH subluxation/dislocation
70
if traumatic injury, what is a common test used initially to r/o dx
radiograph
71
examine impairments related to: (2)
movement dysfunction
irritability stage
72
how can impairments related to movement dysfunction be examined
concordant sign
response to intervention over time
73
what are red flags for palpation
infection
edema
ecchymosis
74
what is the process for inspecting/palpating a shoulder (5)
1. expose region
2. red flags
3. bony alignment
4. resting posture/arm position
5. willingness to move
75
what is one consideration when observing scap position
abnormal static scap position isn't related to movement dysfunction
- static position doesn't necessarily dictate what dynamic function looks like
76
when is observing bony alignment especially important
post trauma
77
what are you looking for when observing resting posture and arm position
muscle atrophy
78
what is included in a neuro screen (3)
reflexes
myotome
dermatome
79
what sx indicate a neuro screen
numbness/tingling, paresthesia, weakness
- periscap
- below elbow
- proximal to AC
80
what tests r/i cervical radiculopathy (4)
ipsilateral rotation <60deg
(+) spurlings
relief w distraction
(+) median nerve ULTT
81
what should be looked at for AROM (4)
pain severity & irritability
quality of motion
overpressure if pain free
scapular motion/winging
82
if motion is pain free w AROM and overpressure, what does this mean
cleared the joint
83
how should scapular winging be assessed
if subtle - test strength
if more pronounced, asymmetric - nerve related
84
what nerves could be involved w scapular winging
long thoracic nerve (inferior border)
spinal accessory nerve (medial border, flip sign)
85
how is passive joint mobility assessed
bilateral comparison
end feel & irritability
anterior / posterolateral / inferior
86
what are region specific outcome measures
DASH
qDASH
PSS
SPADI
87
what pt population are clavicular fx common in
children
88
MOI for clavicular fx (2)
FOOSH
direct impact to clavicle
89
what part of the clavicle is often fx
midshaft
- medial (SC) ligaments
- lateral (AC) ligaments
90
how are clavicular fx mostly managed
conservatively
91
why is ROM limited when treating a clavicular fx
the higher you raise your arm, the more shearing you get at the clavicle
92
what are 2 components of a conservative intervention for clavicular fx
1. figure 8 brace for 3-6wks
2. ROM <90deg initially
93
how does a clavicular fx often heal in conservative approach to treatment
callus forms creating "palpable bump"
94
when is surgical stabilization a viable treatment for clavicular fx (2)
open fx (which is rare)
neurovascular compromise
95
why are scapular fx so rare
lot of muscular protection and soft tissue surrounding it
- would take a significant traumatic event to cause a fx
96
how are scapular fx classified
by location
A. body (most common)
B. glenoid rim
C. intra-articular glenoid
D. neck
E. acromion
F. spine
G. coracoid
97
what is the treatment for scapular fx
conservative
surrounding musculature provides stabilization
98
what are MOI for proximal humerus fx
FOOSH
may occur w dislocation
RC avulsion
subscap avulsion
99
with a proximal humerus fx what is there potential for which is an important consideratioin
neurovascular injury
- ie axillary n.
100
how often is axillary n. implicated in shoulder injuries
innervates deltoid
should be intact w any dislocation, subluxation
- if delt weakness then suspect axillary n.
101
what fx is associated with a rotator cuff avulsion
greater tuberosity humeral fx
102
what is the treatment for a rotator cuff avulsion
>1cm displacement = surgical fixation
103
what fx is associated w subscapularis avulsion
lesser tuberosity humeral fx
104
how are proximal humeral fx described
1part, 2part
- however many pieces the humerus fx into
105
what is the treatment for a nondisplaced proximal humeral fx
immobilized until healed
106
what is an important consideration for nondisplaced humeral fx when it is immobilized while healing
careful to prevent ms from firing bc can make a nondisplaced fx displaced
107
what are 4 ways to manage proximal humerus fx
sling use
promote range
respect pain (tolerable)
strength after mobility gains
108
how should range be promoted when managing a proximal humerus fx
at prox and distal joints
gentle mobilizations
109
what should be considered when looking at strength after mobility gains for proximal humerus fx management
caution w healing segments
110
too much pain after a proximal humerus fx could mean what
body's sign that you are loading something inappropriately
111
what is the most important thing to be promoting when managing a proximal humerus fx
ROM (more important than strength)
- closing window on when you can get mobility back
- rather stay weaker longer while get as much ROM back as possible
if it is innervated, can get strength back (later problem)
112
what are two MOI for proximal humerus fx in adolescents
growth plate fx
rotational forces of pitching
- macrotrauma
- microtrauma d/t traction
113
what adolescent pt population do you likely see proximal humerus fx in
overuse in athletes and pitchers
- can get worse and worse if not adjusting to activity and can impact the growth plate
114
what are the 3 types of AC joint injuries
1 - sprain/partial tear, no displacement
2 - AC torn, CC intact, mild displacement
3 - AC & CC ruptured, complete separation
115
what is the significance of surgical vs nonsurgical management in type 3 AC joint injuries
outcomes are the same
116
what determines how an AC joint injury is managed
where the clavicle ends up
- superior translation - non surgical
- anterior/inferior - surgical
---- worried ab critical structures
117
grade 1-2 vs 3-6 of AC joint injuries
grade 1-2 = partial tears
- recovery depends on deg of lifting and overhead activity
grade 3-6 = complete tears to AC, conoid, and trapezoid
- candidates for surgical repair
118
3 types of surgical AC joint repairs
tightrope fiber/wire
allograft w screw fixation
CC lig reconstruction
119
describe the tightrope fiber surgical intervention for AC joint repair
"tightrope" #5 fiber wire threaded clavicle to coracoid
minimally invasive
120
describe risk of the allograft w screw fixation surgical intervention for AC joint repair
invasive to clavicle, danger of fx
121
what is the most common surgical technique
CC lig reconstruction
- done most often, best results
- most technically demanding
121
what is the most common surgical technique
CC lig reconstruction
- done most often, best results
- most technically demanding
122
describe anatomic CC lig reconstruction as a surgical intervention for AC joint injury
+/- AC lig
gracilis graft (auto) or dacron sutures
optimally only drill one hole in clavicle
- loop around/under coracoid
123
what are 3 rehab considerations for non-op grades 1-2 AC joint injury
1. limit IR, H-ADD initially
2. sling 1-3wks
3. gradual motion and strength
124
what are 3 rehab considerations for post-op an AC joint repair
sling 6-8wks
1. limit elevation <90deg, avoid full IR, H-ADD 3-6wks
2. progress scaption to full ROM >6wks
125
epidemiology for OA
primary - insidious onset
secondary - prior trauma/surgery
- some event has impacted the native anatomy of the joint
126
how does OA present (3)
pain
dec function
dec motion
127
what are general treatment non-op options for OA (3)
PT
NSAIDs
cortisone injection
128
what are physical therapy treatment options for OA (3)
1. pain management
2. capsular mobility
- capsular pattern
- ER, ABD, IR
3. strength/endurance
- RC & scap musculature
129
why is OA so painful
cartilage - aneural
bone - lot of neural innervaiton
- this is what makes arthritis painful, not the cartilage damage itself
130
what are your surgical options for OA (4)
1. focal humeral lesions in articular cartilage (osteophytes)
2. debridement
3. microfx or abrasion
4. osteochondral autograft transfer (OATS)
131
why is focal humeral lesions a viable surgical option for treating OA
drilling holes to cause some bleeding
- create bleeding surface and body grows fibrocartilage
- not as resilient as hyaline cartilage but better than nothing
similar idea to another surgical technique of microfx or abrasion
132
when is TSA indicated
when all else fails
133
who is TSA contraindicated in (3)
1. laborers or high impact/load demands
2. large inoperable RTC tears
3. isolated humeral OA w intact scapular surface
134
what is a better surgical option than TSA for isolated humeral OA w intact scap surface
hemiarthroplasty
135
how do surgical components differ in hemiarthroplasty vs TSA
hemiarthroplasty - humeral component
glenoid component - TSA
136
what are the general considerations for traditional TSA
early on - create healing environment
then focus on mobility
then focus on strengthening
137
what are PT recommendations/precautions for TSA rehab
wk 1-6 subscap precautions
limit ER ROM <30deg
no IR resistive exercise
scap ROM and exercises
early isometrics (no IR)
138
why do you see subscap precautions initially after TSA
detached during procedure
139
what is an important consideration for determining candidacy for a TSA
only works if rotator cuff is still working
140
what surgery is indicated if pt doesn't have functioning rotator cuff
reverse TSA
141
what is the fundamental difference b/w traditional TSA vs reverse TSA
TSA - restore anatomy of convex on concave
reverse TSA - concave head of humerus and convex glenoid
142
why does a reverse TSA work for someone with no rotator cuff function when a traditional TSA wouldn't
in reverse TSA - you reverse the anatomy so that shoulder can pivot over reverse prosthesis when deltoid activates
- prevents the compensatory shrug you see w elevation if rotator cuff not functioning
aka creates advantage in absence of functional RC by inc the deltoid lever arm
143
what motion is especially more powerful following a reverse TSA
ABD
144
what happens to the center of rotation after a reverse TSA
medializes it
145
what motion is reduced after a reverse TSA
ER strength and AROM
146
what is a con to reverse TSA over TSA
more technically difficult and demanding
147
what is the overall goal after a reverse TSA
restore overhead motion
148
indications for a reverse TSA (2)
massive RC tear
failed TSA w deficient RC
149
contraindications to reverse TSA (3)
1. active infection
2. impaired deltoid function
- ie axillary n injury
3. need for high level shoulder function
150
at are 2 general rehab considerations after a reverse TSA
1. immobilizer sling first 4-6wks
2. dislocation from combined IR/ADD/ER
151
how could you dislocate after a reverse TSA? why is this?
combined IR/ADD/ER
- d/t subscap status following deltopectoral approach
152
general progression of PT interventions after reverse TSA
PROM/AAROM
- elevation and ER
AROM as tolerated and delt iso
gradual inc in load and reps w exercise
153
what is implicated if there is superior shoulder pain
AC joint
154
what is implicated if there is lateral shoulder pain
RC
155
what is implicated if there is anterior shoulder pain
biceps
156
what is implicated if there is deep shoulder pain
labrum/capsule
