9/20 - Shoulder Exam Anatomy, Fx, OA, TSA Flashcards
what is the significance of the sternoclavicular joint
only skeletal articulation to axial region
describe the anatomy of the glenoid fossa
pear-shaped
- anteverted 30
- tipped superiorly
posterior portion of capsule is thin
what are the passive structures associated w shoulder anatomy
bony surfaces
- humeral head
- glenoid
capsulolabral ligamentous complex
- A/P capsule
- anterior GH ligaments
- A/P labrum
what are the active structures associated with shoulder anatomy
rotator cuff
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
long head of biceps
what function does the long head of the biceps serve
position of ABD & ER
controls superior and anterior translation
describe the biomechanics of scapulohumeral rhythm
2deg of GH motion for every
1deg of ST motion
180 shoulder elevation
- 120 humeral elevation
- 60 scapular rotation
what are force couples associated w the shoulder
deltoid - rotator cuff (supra)
anterior - posterior rotator cuff
trap - serratus anterior
if there is unopposed deltoid force, what is the result
superior migration
what are the primary forces at the shoulder
deltoid / rotator cuff (supraspinatus)
what is the rotator cuff’s primary job
keeping head of humerus centered in glenoid
what do you usually see in someone with cuff pathology
compensatory shrug
where does most cuff pathology start
at supraspinatus
if have supraspinatus pathology, what does this mean for shoulder stabilization
will probably still be relatively stable due to anterior - posterior rotator cuff force couple
pathology affecting what muscles will result in visible pronounced deficits
as damage extends and affects the AP force couple
what muscles are involved in the anterior-posterior rotator cuff force couple
anterior - subscapularis
posterior - infraspinatus, teres minor
what motions do the trap-serratus anterior force couple create/assist with
shoulder elevation
upward rotation of scapula
posterior tilt of scapula
what are 4 functions of the trap-serratus anterior force couple
- optimal position of glenoid
- deltoid length - tension
- prevents impingement
- stable base to recruit scapular musculature
how does the T-SA force couple relate to the deltoid
gives ideal length-tension for deltoid to work
tissue amt in anterior GH vs posterior
tissue tends to be more robust anteriorly
- posterior GH is thin
what are ligaments
thickenings of GH capsule
what force couple is important for overhead functioning
trap - serratus anterior
shoulder complaints not d/t traumas are often d/t
imbalances in T-SA force couples
what is the significance of T-SA creating UR and posterior tilt of the scap
allows for clearance under coracoacromial arch to prevent impingement and normal overhead functioning
where does impingement happen
between acromion and humerus
- lot of stuff lives there
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
where will pain from subacromial structures and GH joint present
distal to acromion in lateral deltoid region
where will pain from AC joint present
top of acromion surrounding AC joint
sx at top of shoulder, sus of what
AC joint
sx at anterolateral shoulder, sus of what
RC
subacromial syndrome
how does RC pathology present
pain beneath acromion and lateral to deltoid region
what is a common location for arthritis
AC joint (top of shoulder)
what common shoulder paths have a overuse MOI
tendinopathy
atraumatic instability
what common shoulder paths have a trauma MOI
fx
RC tear
AC separation
GH sublux/dislocation
what are 7 things to ask about if someone is experiencing pain
- MOI
- aggravating factors
- alleviating factors
- 24 hour pattern
- pain severity
- pain irritability
- chronicity
adhesive capsulitis (primary) sx (3)
persistent anterior-lateral shoulder pain
inability to sleep d/t pain
gradual loss of motion
- mostly ER limited
risk factors of adhesive capsulitis (primary) - 4
females
40-65yo
DM
hypothyroidism
GH OA (primary) sx - 2
gradual onset of pain & loss of motion
stiffness in morning
risk factor for GH OA (primary)
> 60yo
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
AC joint arthropathy/injury associated hx (2)
heavy weightlifting
contact trauma w inferior force
subacromial pain syndrome sx (4)
- anterior-lateral shoulder pain
- pain w motion at or above shoulder height
- painful arc w active elevation
- inc pain at night
what are 2 tests that can be done to r/i subacromial pain syndrome
(+) impingement signs
(+) LHBT tests
what pathology do you see a painful arc in other than subacromial pain syndrome
abnormal/injured trap-SA force couple
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
rotator cuff tear sx - 5
anterior lateral shoulder pain
limited strength
pain wakes during sleep
pain worse at night
(+) Lag signs
what is a risk factor for rotator cuff tears
40yo
what would a pt w GH OA (primary) c/o
crepitus or catching with end ROM
anterior instability or labral tear sx - 2
anterior shoulder pain
apprehension/pain end range ABD-ER
anterior instability or labral tear common hx (2)
ant-inferior trauma
recurrent sublux/dislocations
what would a pt w anterior instability or a labral tear c/o
clicking/clunking
locking
“dead arm syndrome”
is anterior or posterior instability more common
anterior
what pt population do you frequently see anterior instability in
throwers and overuse athletes
posterior instability sx
apprehension/pain in combined flexion and horizontal ADD w posterior force
posterior instability common hx
trauma w recurrent sublux/dislocations
- aka FOOSH
posterior instability c/o
pain w pushing/CKC activity
posterior internal impingement sx
posterior pain in late cocking phase (think pitcher)
- aka ABD-ER with horizontal plane hyper-ABD
dec performance
SLAP lesions sx
deep anterior pain w mechanical sx
pain w throwing or biceps loading
what does SLAP stand for
Superior Labrum from Anterior to Posterior tear
what is LHB
long head of biceps
LHB tendinopathy sx
anterior pain isolate to LHBT in groove w shoulder flex & arm supination
what are the stages of irritability
low
moderate
high
what does high irritability mean
pain >7/10
constant night or rest pain
constant sx
high disability level
what does moderate irritability mean
pain 4-6/10
intermittent pain
moderate disability level
what does low irritability mean
pain <3/10
no resting or night pain
low disability level
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
what is a risk factor for polymyalgia rheumatica
> 60yo
what nerves do you typically see nerve palsy in that may refer pain to the shoulder
long thoracic
spinal accessory
what are overuse injuries (2)
tendinopathy
atraumatic instability
what are traumatic injuries (4)
fx
RC tear
AC joint separation
GH subluxation/dislocation
if traumatic injury, what is a common test used initially to r/o dx
radiograph
examine impairments related to: (2)
movement dysfunction
irritability stage
how can impairments related to movement dysfunction be examined
concordant sign
response to intervention over time
what are red flags for palpation
infection
edema
ecchymosis
what is the process for inspecting/palpating a shoulder (5)
- expose region
- red flags
- bony alignment
- resting posture/arm position
- willingness to move
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
when is observing bony alignment especially important
post trauma
what are you looking for when observing resting posture and arm position
muscle atrophy
what is included in a neuro screen (3)
reflexes
myotome
dermatome
what sx indicate a neuro screen
numbness/tingling, paresthesia, weakness
- periscap
- below elbow
- proximal to AC
what tests r/i cervical radiculopathy (4)
ipsilateral rotation <60deg
(+) spurlings
relief w distraction
(+) median nerve ULTT
what should be looked at for AROM (4)
pain severity & irritability
quality of motion
overpressure if pain free
scapular motion/winging
if motion is pain free w AROM and overpressure, what does this mean
cleared the joint
how should scapular winging be assessed
if subtle - test strength
if more pronounced, asymmetric - nerve related
what nerves could be involved w scapular winging
long thoracic nerve (inferior border)
spinal accessory nerve (medial border, flip sign)
how is passive joint mobility assessed
bilateral comparison
end feel & irritability
anterior / posterolateral / inferior
what are region specific outcome measures
DASH
qDASH
PSS
SPADI
what pt population are clavicular fx common in
children
MOI for clavicular fx (2)
FOOSH
direct impact to clavicle
what part of the clavicle is often fx
midshaft
- medial (SC) ligaments
- lateral (AC) ligaments
how are clavicular fx mostly managed
conservatively
why is ROM limited when treating a clavicular fx
the higher you raise your arm, the more shearing you get at the clavicle
what are 2 components of a conservative intervention for clavicular fx
- figure 8 brace for 3-6wks
- ROM <90deg initially
how does a clavicular fx often heal in conservative approach to treatment
callus forms creating “palpable bump”
when is surgical stabilization a viable treatment for clavicular fx (2)
open fx (which is rare)
neurovascular compromise
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
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
what is the treatment for scapular fx
conservative
surrounding musculature provides stabilization
what are MOI for proximal humerus fx
FOOSH
may occur w dislocation
RC avulsion
subscap avulsion
with a proximal humerus fx what is there potential for which is an important consideratioin
neurovascular injury
- ie axillary n.
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.
what fx is associated with a rotator cuff avulsion
greater tuberosity humeral fx
what is the treatment for a rotator cuff avulsion
> 1cm displacement = surgical fixation
what fx is associated w subscapularis avulsion
lesser tuberosity humeral fx
how are proximal humeral fx described
1part, 2part
- however many pieces the humerus fx into
what is the treatment for a nondisplaced proximal humeral fx
immobilized until healed
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
what are 4 ways to manage proximal humerus fx
sling use
promote range
respect pain (tolerable)
strength after mobility gains
how should range be promoted when managing a proximal humerus fx
at prox and distal joints
gentle mobilizations
what should be considered when looking at strength after mobility gains for proximal humerus fx management
caution w healing segments
too much pain after a proximal humerus fx could mean what
body’s sign that you are loading something inappropriately
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)
what are two MOI for proximal humerus fx in adolescents
growth plate fx
rotational forces of pitching
- macrotrauma
- microtrauma d/t traction
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
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
what is the significance of surgical vs nonsurgical management in type 3 AC joint injuries
outcomes are the same
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
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
3 types of surgical AC joint repairs
tightrope fiber/wire
allograft w screw fixation
CC lig reconstruction
describe the tightrope fiber surgical intervention for AC joint repair
“tightrope” #5 fiber wire threaded clavicle to coracoid
minimally invasive
describe risk of the allograft w screw fixation surgical intervention for AC joint repair
invasive to clavicle, danger of fx
what is the most common surgical technique
CC lig reconstruction
- done most often, best results
- most technically demanding
what is the most common surgical technique
CC lig reconstruction
- done most often, best results
- most technically demanding
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
what are 3 rehab considerations for non-op grades 1-2 AC joint injury
- limit IR, H-ADD initially
- sling 1-3wks
- gradual motion and strength
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
epidemiology for OA
primary - insidious onset
secondary - prior trauma/surgery
- some event has impacted the native anatomy of the joint
how does OA present (3)
pain
dec function
dec motion
what are general treatment non-op options for OA (3)
PT
NSAIDs
cortisone injection
what are physical therapy treatment options for OA (3)
- pain management
- capsular mobility
- capsular pattern
- ER, ABD, IR - strength/endurance
- RC & scap musculature
why is OA so painful
cartilage - aneural
bone - lot of neural innervaiton
- this is what makes arthritis painful, not the cartilage damage itself
what are your surgical options for OA (4)
- focal humeral lesions in articular cartilage (osteophytes)
- debridement
- microfx or abrasion
- osteochondral autograft transfer (OATS)
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
when is TSA indicated
when all else fails
who is TSA contraindicated in (3)
- laborers or high impact/load demands
- large inoperable RTC tears
- isolated humeral OA w intact scapular surface
what is a better surgical option than TSA for isolated humeral OA w intact scap surface
hemiarthroplasty
how do surgical components differ in hemiarthroplasty vs TSA
hemiarthroplasty - humeral component
glenoid component - TSA
what are the general considerations for traditional TSA
early on - create healing environment
then focus on mobility
then focus on strengthening
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)
why do you see subscap precautions initially after TSA
detached during procedure
what is an important consideration for determining candidacy for a TSA
only works if rotator cuff is still working
what surgery is indicated if pt doesn’t have functioning rotator cuff
reverse TSA
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
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
what motion is especially more powerful following a reverse TSA
ABD
what happens to the center of rotation after a reverse TSA
medializes it
what motion is reduced after a reverse TSA
ER strength and AROM
what is a con to reverse TSA over TSA
more technically difficult and demanding
what is the overall goal after a reverse TSA
restore overhead motion
indications for a reverse TSA (2)
massive RC tear
failed TSA w deficient RC
contraindications to reverse TSA (3)
- active infection
- impaired deltoid function
- ie axillary n injury - need for high level shoulder function
at are 2 general rehab considerations after a reverse TSA
- immobilizer sling first 4-6wks
- dislocation from combined IR/ADD/ER
how could you dislocate after a reverse TSA? why is this?
combined IR/ADD/ER
- d/t subscap status following deltopectoral approach
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
what is implicated if there is superior shoulder pain
AC joint
what is implicated if there is lateral shoulder pain
RC
what is implicated if there is anterior shoulder pain
biceps
what is implicated if there is deep shoulder pain
labrum/capsule
