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MSK 1 > 9/20 - Shoulder Exam Anatomy, Fx, OA, TSA > Flashcards

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

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2
Q

describe the anatomy of the glenoid fossa

A

pear-shaped
- anteverted 30
- tipped superiorly

posterior portion of capsule is thin

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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

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4
Q

what are the active structures associated with shoulder anatomy

A

rotator cuff
- supraspinatus
- infraspinatus
- teres minor
- subscapularis

long head of biceps

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5
Q

what function does the long head of the biceps serve

A

position of ABD & ER

controls superior and anterior translation

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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

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7
Q

what are force couples associated w the shoulder

A

deltoid - rotator cuff (supra)
anterior - posterior rotator cuff
trap - serratus anterior

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8
Q

if there is unopposed deltoid force, what is the result

A

superior migration

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9
Q

what are the primary forces at the shoulder

A

deltoid / rotator cuff (supraspinatus)

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10
Q

what is the rotator cuff’s primary job

A

keeping head of humerus centered in glenoid

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11
Q

what do you usually see in someone with cuff pathology

A

compensatory shrug

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12
Q

where does most cuff pathology start

A

at supraspinatus

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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

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14
Q

pathology affecting what muscles will result in visible pronounced deficits

A

as damage extends and affects the AP force couple

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15
Q

what muscles are involved in the anterior-posterior rotator cuff force couple

A

anterior - subscapularis
posterior - infraspinatus, teres minor

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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

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17
Q

what are 4 functions of the trap-serratus anterior force couple

A
  1. optimal position of glenoid
  2. deltoid length - tension
  3. prevents impingement
  4. stable base to recruit scapular musculature
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18
Q

how does the T-SA force couple relate to the deltoid

A

gives ideal length-tension for deltoid to work

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19
Q

tissue amt in anterior GH vs posterior

A

tissue tends to be more robust anteriorly
- posterior GH is thin

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20
Q

what are ligaments

A

thickenings of GH capsule

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21
Q

what force couple is important for overhead functioning

A

trap - serratus anterior

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22
Q

shoulder complaints not d/t traumas are often d/t

A

imbalances in T-SA force couples

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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

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24
Q

where does impingement happen

A

between acromion and humerus
- lot of stuff lives there

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25
Q

what are 4 types of pain that can be associated with the shoulder

A

cervical referral (facet/disc)
visceral/vascular referral
subacromial structures & GH joint
AC joint

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26
Q

where will pain from subacromial structures and GH joint present

A

distal to acromion in lateral deltoid region

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27
Q

where will pain from AC joint present

A

top of acromion surrounding AC joint

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28
Q

sx at top of shoulder, sus of what

A

AC joint

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29
Q

sx at anterolateral shoulder, sus of what

A

RC
subacromial syndrome

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30
Q

how does RC pathology present

A

pain beneath acromion and lateral to deltoid region

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31
Q

what is a common location for arthritis

A

AC joint (top of shoulder)

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32
Q

what common shoulder paths have a overuse MOI

A

tendinopathy
atraumatic instability

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33
Q

what common shoulder paths have a trauma MOI

A

fx
RC tear
AC separation
GH sublux/dislocation

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34
Q

what are 7 things to ask about if someone is experiencing pain

A
  1. MOI
  2. aggravating factors
  3. alleviating factors
  4. 24 hour pattern
  5. pain severity
  6. pain irritability
  7. chronicity
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35
Q

adhesive capsulitis (primary) sx (3)

A

persistent anterior-lateral shoulder pain
inability to sleep d/t pain
gradual loss of motion
- mostly ER limited

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36
Q

risk factors of adhesive capsulitis (primary) - 4

A

females
40-65yo
DM
hypothyroidism

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37
Q

GH OA (primary) sx - 2

A

gradual onset of pain & loss of motion
stiffness in morning

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38
Q

risk factor for GH OA (primary)

A

> 60yo

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39
Q

AC joint arthropathy/injury sx - 3

A

pain at top of shoulder near AC
inc pain end range elevation and/or horizontal ADD

may have visual deformity

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40
Q

AC joint arthropathy/injury associated hx (2)

A

heavy weightlifting
contact trauma w inferior force

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41
Q

subacromial pain syndrome sx (4)

A
  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
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42
Q

what are 2 tests that can be done to r/i subacromial pain syndrome

A

(+) impingement signs
(+) LHBT tests

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43
Q

what pathology do you see a painful arc in other than subacromial pain syndrome

A

abnormal/injured trap-SA force couple

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44
Q

describe the painful arc seen w subacromial pain syndrome

A

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

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45
Q

rotator cuff tear sx - 5

A

anterior lateral shoulder pain
limited strength
pain wakes during sleep
pain worse at night
(+) Lag signs

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46
Q

what is a risk factor for rotator cuff tears

A

40yo

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47
Q

what would a pt w GH OA (primary) c/o

A

crepitus or catching with end ROM

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48
Q

anterior instability or labral tear sx - 2

A

anterior shoulder pain
apprehension/pain end range ABD-ER

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49
Q

anterior instability or labral tear common hx (2)

A

ant-inferior trauma
recurrent sublux/dislocations

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50
Q

what would a pt w anterior instability or a labral tear c/o

A

clicking/clunking
locking
“dead arm syndrome”

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51
Q

is anterior or posterior instability more common

A

anterior

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52
Q

what pt population do you frequently see anterior instability in

A

throwers and overuse athletes

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53
Q

posterior instability sx

A

apprehension/pain in combined flexion and horizontal ADD w posterior force

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54
Q

posterior instability common hx

A

trauma w recurrent sublux/dislocations
- aka FOOSH

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55
Q

posterior instability c/o

A

pain w pushing/CKC activity

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56
Q

posterior internal impingement sx

A

posterior pain in late cocking phase (think pitcher)
- aka ABD-ER with horizontal plane hyper-ABD

dec performance

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57
Q

SLAP lesions sx

A

deep anterior pain w mechanical sx
pain w throwing or biceps loading

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58
Q

what does SLAP stand for

A

Superior Labrum from Anterior to Posterior tear

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59
Q

what is LHB

A

long head of biceps

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60
Q

LHB tendinopathy sx

A

anterior pain isolate to LHBT in groove w shoulder flex & arm supination

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61
Q

what are the stages of irritability

A

low
moderate
high

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62
Q

what does high irritability mean

A

pain >7/10
constant night or rest pain
constant sx

high disability level

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63
Q

what does moderate irritability mean

A

pain 4-6/10
intermittent pain

moderate disability level

64
Q

what does low irritability mean

A

pain <3/10
no resting or night pain

low disability level

65
Q

what are red flags that will probably require a referral out (7)

A

tumors
infection
visceral pathology
rheumatological conditions
polymyalgia rheumatica
nerve palsy
parsonage-turner syndrome

66
Q

what is a risk factor for polymyalgia rheumatica

A

> 60yo

67
Q

what nerves do you typically see nerve palsy in that may refer pain to the shoulder

A

long thoracic
spinal accessory

68
Q

what are overuse injuries (2)

A

tendinopathy
atraumatic instability

69
Q

what are traumatic injuries (4)

A

fx
RC tear
AC joint separation
GH subluxation/dislocation

70
Q

if traumatic injury, what is a common test used initially to r/o dx

A

radiograph

71
Q

examine impairments related to: (2)

A

movement dysfunction
irritability stage

72
Q

how can impairments related to movement dysfunction be examined

A

concordant sign
response to intervention over time

73
Q

what are red flags for palpation

A

infection
edema
ecchymosis

74
Q

what is the process for inspecting/palpating a shoulder (5)

A
  1. expose region
  2. red flags
  3. bony alignment
  4. resting posture/arm position
  5. willingness to move
75
Q

what is one consideration when observing scap position

A

abnormal static scap position isn’t related to movement dysfunction
- static position doesn’t necessarily dictate what dynamic function looks like

76
Q

when is observing bony alignment especially important

A

post trauma

77
Q

what are you looking for when observing resting posture and arm position

A

muscle atrophy

78
Q

what is included in a neuro screen (3)

A

reflexes
myotome
dermatome

79
Q

what sx indicate a neuro screen

A

numbness/tingling, paresthesia, weakness
- periscap
- below elbow
- proximal to AC

80
Q

what tests r/i cervical radiculopathy (4)

A

ipsilateral rotation <60deg
(+) spurlings
relief w distraction
(+) median nerve ULTT

81
Q

what should be looked at for AROM (4)

A

pain severity & irritability
quality of motion
overpressure if pain free
scapular motion/winging

82
Q

if motion is pain free w AROM and overpressure, what does this mean

A

cleared the joint

83
Q

how should scapular winging be assessed

A

if subtle - test strength
if more pronounced, asymmetric - nerve related

84
Q

what nerves could be involved w scapular winging

A

long thoracic nerve (inferior border)
spinal accessory nerve (medial border, flip sign)

85
Q

how is passive joint mobility assessed

A

bilateral comparison
end feel & irritability
anterior / posterolateral / inferior

86
Q

what are region specific outcome measures

A

DASH
qDASH
PSS
SPADI

87
Q

what pt population are clavicular fx common in

A

children

88
Q

MOI for clavicular fx (2)

A

FOOSH
direct impact to clavicle

89
Q

what part of the clavicle is often fx

A

midshaft
- medial (SC) ligaments
- lateral (AC) ligaments

90
Q

how are clavicular fx mostly managed

A

conservatively

91
Q

why is ROM limited when treating a clavicular fx

A

the higher you raise your arm, the more shearing you get at the clavicle

92
Q

what are 2 components of a conservative intervention for clavicular fx

A
  1. figure 8 brace for 3-6wks
  2. ROM <90deg initially
93
Q

how does a clavicular fx often heal in conservative approach to treatment

A

callus forms creating “palpable bump”

94
Q

when is surgical stabilization a viable treatment for clavicular fx (2)

A

open fx (which is rare)
neurovascular compromise

95
Q

why are scapular fx so rare

A

lot of muscular protection and soft tissue surrounding it
- would take a significant traumatic event to cause a fx

96
Q

how are scapular fx classified

A

by location
A. body (most common)
B. glenoid rim
C. intra-articular glenoid
D. neck
E. acromion
F. spine
G. coracoid

97
Q

what is the treatment for scapular fx

A

conservative
surrounding musculature provides stabilization

98
Q

what are MOI for proximal humerus fx

A

FOOSH
may occur w dislocation
RC avulsion
subscap avulsion

99
Q

with a proximal humerus fx what is there potential for which is an important consideratioin

A

neurovascular injury
- ie axillary n.

100
Q

how often is axillary n. implicated in shoulder injuries

A

innervates deltoid

should be intact w any dislocation, subluxation
- if delt weakness then suspect axillary n.

101
Q

what fx is associated with a rotator cuff avulsion

A

greater tuberosity humeral fx

102
Q

what is the treatment for a rotator cuff avulsion

A

> 1cm displacement = surgical fixation

103
Q

what fx is associated w subscapularis avulsion

A

lesser tuberosity humeral fx

104
Q

how are proximal humeral fx described

A

1part, 2part
- however many pieces the humerus fx into

105
Q

what is the treatment for a nondisplaced proximal humeral fx

A

immobilized until healed

106
Q

what is an important consideration for nondisplaced humeral fx when it is immobilized while healing

A

careful to prevent ms from firing bc can make a nondisplaced fx displaced

107
Q

what are 4 ways to manage proximal humerus fx

A

sling use
promote range
respect pain (tolerable)
strength after mobility gains

108
Q

how should range be promoted when managing a proximal humerus fx

A

at prox and distal joints
gentle mobilizations

109
Q

what should be considered when looking at strength after mobility gains for proximal humerus fx management

A

caution w healing segments

110
Q

too much pain after a proximal humerus fx could mean what

A

body’s sign that you are loading something inappropriately

111
Q

what is the most important thing to be promoting when managing a proximal humerus fx

A

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
Q

what are two MOI for proximal humerus fx in adolescents

A

growth plate fx
rotational forces of pitching
- macrotrauma
- microtrauma d/t traction

113
Q

what adolescent pt population do you likely see proximal humerus fx in

A

overuse in athletes and pitchers
- can get worse and worse if not adjusting to activity and can impact the growth plate

114
Q

what are the 3 types of AC joint injuries

A

1 - sprain/partial tear, no displacement
2 - AC torn, CC intact, mild displacement
3 - AC & CC ruptured, complete separation

115
Q

what is the significance of surgical vs nonsurgical management in type 3 AC joint injuries

A

outcomes are the same

116
Q

what determines how an AC joint injury is managed

A

where the clavicle ends up
- superior translation - non surgical
- anterior/inferior - surgical
—- worried ab critical structures

117
Q

grade 1-2 vs 3-6 of AC joint injuries

A

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
Q

3 types of surgical AC joint repairs

A

tightrope fiber/wire
allograft w screw fixation
CC lig reconstruction

119
Q

describe the tightrope fiber surgical intervention for AC joint repair

A

“tightrope” #5 fiber wire threaded clavicle to coracoid

minimally invasive

120
Q

describe risk of the allograft w screw fixation surgical intervention for AC joint repair

A

invasive to clavicle, danger of fx

121
Q

what is the most common surgical technique

A

CC lig reconstruction
- done most often, best results
- most technically demanding

121
Q

what is the most common surgical technique

A

CC lig reconstruction
- done most often, best results
- most technically demanding

122
Q

describe anatomic CC lig reconstruction as a surgical intervention for AC joint injury

A

+/- AC lig
gracilis graft (auto) or dacron sutures
optimally only drill one hole in clavicle
- loop around/under coracoid

123
Q

what are 3 rehab considerations for non-op grades 1-2 AC joint injury

A
  1. limit IR, H-ADD initially
  2. sling 1-3wks
  3. gradual motion and strength
124
Q

what are 3 rehab considerations for post-op an AC joint repair

A

sling 6-8wks
1. limit elevation <90deg, avoid full IR, H-ADD 3-6wks
2. progress scaption to full ROM >6wks

125
Q

epidemiology for OA

A

primary - insidious onset

secondary - prior trauma/surgery
- some event has impacted the native anatomy of the joint

126
Q

how does OA present (3)

A

pain
dec function
dec motion

127
Q

what are general treatment non-op options for OA (3)

A

PT
NSAIDs
cortisone injection

128
Q

what are physical therapy treatment options for OA (3)

A
  1. pain management
  2. capsular mobility
    - capsular pattern
    - ER, ABD, IR
  3. strength/endurance
    - RC & scap musculature
129
Q

why is OA so painful

A

cartilage - aneural
bone - lot of neural innervaiton
- this is what makes arthritis painful, not the cartilage damage itself

130
Q

what are your surgical options for OA (4)

A
  1. focal humeral lesions in articular cartilage (osteophytes)
  2. debridement
  3. microfx or abrasion
  4. osteochondral autograft transfer (OATS)
131
Q

why is focal humeral lesions a viable surgical option for treating OA

A

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
Q

when is TSA indicated

A

when all else fails

133
Q

who is TSA contraindicated in (3)

A
  1. laborers or high impact/load demands
  2. large inoperable RTC tears
  3. isolated humeral OA w intact scapular surface
134
Q

what is a better surgical option than TSA for isolated humeral OA w intact scap surface

A

hemiarthroplasty

135
Q

how do surgical components differ in hemiarthroplasty vs TSA

A

hemiarthroplasty - humeral component
glenoid component - TSA

136
Q

what are the general considerations for traditional TSA

A

early on - create healing environment
then focus on mobility
then focus on strengthening

137
Q

what are PT recommendations/precautions for TSA rehab

A

wk 1-6 subscap precautions
limit ER ROM <30deg
no IR resistive exercise
scap ROM and exercises
early isometrics (no IR)

138
Q

why do you see subscap precautions initially after TSA

A

detached during procedure

139
Q

what is an important consideration for determining candidacy for a TSA

A

only works if rotator cuff is still working

140
Q

what surgery is indicated if pt doesn’t have functioning rotator cuff

A

reverse TSA

141
Q

what is the fundamental difference b/w traditional TSA vs reverse TSA

A

TSA - restore anatomy of convex on concave

reverse TSA - concave head of humerus and convex glenoid

142
Q

why does a reverse TSA work for someone with no rotator cuff function when a traditional TSA wouldn’t

A

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
Q

what motion is especially more powerful following a reverse TSA

A

ABD

144
Q

what happens to the center of rotation after a reverse TSA

A

medializes it

145
Q

what motion is reduced after a reverse TSA

A

ER strength and AROM

146
Q

what is a con to reverse TSA over TSA

A

more technically difficult and demanding

147
Q

what is the overall goal after a reverse TSA

A

restore overhead motion

148
Q

indications for a reverse TSA (2)

A

massive RC tear
failed TSA w deficient RC

149
Q

contraindications to reverse TSA (3)

A
  1. active infection
  2. impaired deltoid function
    - ie axillary n injury
  3. need for high level shoulder function
150
Q

at are 2 general rehab considerations after a reverse TSA

A
  1. immobilizer sling first 4-6wks
  2. dislocation from combined IR/ADD/ER
151
Q

how could you dislocate after a reverse TSA? why is this?

A

combined IR/ADD/ER
- d/t subscap status following deltopectoral approach

152
Q

general progression of PT interventions after reverse TSA

A

PROM/AAROM
- elevation and ER
AROM as tolerated and delt iso
gradual inc in load and reps w exercise

153
Q

what is implicated if there is superior shoulder pain

A

AC joint

154
Q

what is implicated if there is lateral shoulder pain

A

RC

155
Q

what is implicated if there is anterior shoulder pain

A

biceps

156
Q

what is implicated if there is deep shoulder pain

A

labrum/capsule

MSK 1 (31 decks)

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