Ch 4 - MSK: Shoulder Flashcards
Describe normal ROM of the shoulder
• Flexion: 180° • Extension: 60° • Abduction: 180° – 120° w/ thumb down • Adduction: 60° • IR: 90° (w/ arm ABD) • ER: 90° (w/ arm ABD)
Describe muscles and innervation involved with shoulder flexion. (4 muscles)
- Anterior deltoid
- Pectoralis major, clavicular portion
- Biceps brachii
- Coracobrachialis
Describe muscles and innervation involved with shoulder extension. (5 muscles)
- Posterior deltoid
- Lat
- Teres major
- Triceps, long head
- Pec major, sternocostal portion
Describe muscles and innervation involved with shoulder ABDuction. (2 muscles)
- Middle deltoid
* Supraspinatus
Describe muscles and innervation involved with shoulder ADDuction. (7 muscles)
- Pec major
- Lat
- Teres major
- Coracobrachialis
- Infraspinatus
- Long head of triceps
- Anterior and posterior deltoid
Describe muscles and innervation involved with shoulder internal rotation. (5 muscles)
- Subscapularis
- Pec major
- Lat
- Anterior deltoid
- Teres major
Describe muscles and innervation involved with shoulder external rotation. (4 muscles)
- Infraspinatus
- Teres minor
- Deltoid, posterior portion
- Supraspinatus
How is arm abduction achieved?
Glenohumeral and scapulothoracic joint motion
There are _____ for every ____ during arm abduction
2 degrees glenohumeral motion for ever 1 degree of scapulothoracic motion
What does scapulothoracic motion allow?
Glenoid to rotate and permits glenohumeral abduction without acromial impingement
What % of the humeral head articulates with the glenoid fossa?
30%
What does the labrum prevent (shoulder)?
Anterior and posterior humeral head dislocation
What % does the labrum increase humeral contact with the glenoid?
70%
What is the purpose the superior glenohumeral ligament?
– Prevents inferior translation
– Provides stability from 0° to 90° of abduction with middle GHL
What is the purpose the middle glenohumeral ligament?
Prevents anterior shoulder translation
What is the purpose the inferior glenohumeral ligament?
Primary anterior ligament stabilizer above 90°
What are the dynamic stabilizers of the shoulder? (6 parts)
- Rotator cuff muscles
- Long head of the biceps tendon
- Deltoid
- Teres major
- Latissimus dorsi
- Scapular stabilizers
What are the static stabilizers of the shoulder? (4 parts)
Glenoid
Labrum
Capsule
Glenohumeral ligament
What are the ligaments of the AC joint? (3 ligaments)
AC ligament
Coracoclavicular ligament
Coracoacromial ligament
What does the AC ligament provide?
Horizontal stability
What does the CC ligament prevent?
Prevents vertical translation of the clavicle
Describe a type I AC separation.
Clavicle not elevated
AC lig: mild sprain
CC lig: intact
Describe a type II AC separation.
Clavicle not above the superior border of the acromion AC lig: ruptured CC lig: sprain Joint capsule: ruptured Deltoid: min detached Trapezius: min detached
Describe a type III AC separation.
Clavicle elevated above the superior border of the acromion but coracoclavicular distance is less than twice normal (i.e. <25 mm) AC lig: ruptured CC lig: ruptured joint capsule: ruptured deltoid: detached trapezius: detached
Describe a type IV AC separation.
Posterior and superior into the trapezius, giving a buttonhole appearance AC lig: ruptured CC lig: ruptured joint capsule: ruptured deltoid: detached trapezius: detached
Describe a type V AC separation.
Clavicle is markedly elevated and coracoclavicular distance is more than double normal (i.e. >25 mm) AC lig: ruptured CC lig: ruptured joint capsule: ruptured deltoid: detached trapezius: detached
Describe a type VI AC separation.
Clavicle inferiorly displaced behind coracobrachialis and biceps tendons, which is rare AC lig: ruptured CC lig: ruptured joint capsule: ruptured deltoid: detached trapezius: detached
Describe the Cross-chest (horizontal adduction or scarf) test.
Passive adduction of the arm across the midline causing joint tenderness
*AC Joint Impingement test
What type of x-rays should be done for AC separation?
Weighted anterior-posterior (AP) radiographs of the shoulders (10 lb)
What is seen on radiographs in a type III and V AC separation?
– Type III: 25% to 100% widening of the clavicular–coracoid area
– Type V: widening >100%
Describe treatment for a Type I and II AC separation.
– Rest, ice, NSAIDs
– Sling for comfort for the first 1 to 2 wks
– Avoid heavy lifting and contact sports
– Shoulder–girdle complex stabilization and strengthening
– RTP: asx w/ full ROM
Type I: 2 weeks
Type II: 6 weeks
Describe treatment for a Type III AC separation.
Surgical for those indicated (heavy laborers, athletes)
Describe treatment for a Type IV, V and VI AC separation.
ORIF or distal clavicular resection with reconstruction of the CC ligament
What are complications of AC joint injuries?
- Clavicular fxs and dislocations
- Distal clavicle osteolysis
- AC joint arthritis
What is Distal clavicle osteolysis?
Degeneration of the distal clavicle with associated osteopenia and cystic changes
What is GHJ instability?
Translation of the humeral head on the glenoid fossa
What is GHJ subluxation?
Incomplete separation of the humeral head from the glenoid fossa with immediate reduction
What is GHJ dislocation?
Complete separation of the humeral head from the glenoid fossa without immediate reduction
What is the most common direction of GHJ instability?
Anterior inferior
What is the mechanism of anterior GHJ instability? (arm motions)
Arm abduction and ER
Who most commonly has anterior GHJ instability?
Younger population and has a high recurrence rate
What are complications of anterior GHJ instability?
Axillary nerve injury
What is the mechanism of posterior GHJ instability?
Landing on a forward flexed ADDucted arm
Seizures
How does a patient with posterior GHJ instability present?
Arm ADDucted and IR position
What are traumatic patterns of GHJ instability?
"T.U.B.S." T - Traumatic shoulder instability U - Unidirectional B - Bankart lesion S - Surgical management
What are atraumatic patterns of GHJ instability?
"A.M.B.R.I." A - Atraumatic shoulder instability M - Multidirectional instability B - Bilateral lesions R - Rehabilitation management I - Inferior capsular shift, if surgery
Describe a Bankart lesion.
Labral tear of the anterior glenoid allows the humeral head to slip anteriorly and may be associated with avulsion fx of glenoid rim
What direction of GHJ dislocation are Bankart lesions associated with?
Anterior dislocations
Describe a Hill-Sachs lesion.
Compression fracture of the posterolateral humeral head caused by abutment against the anterior rim of the glenoid fossa
What direction of GHJ dislocation are Hill-Sachs lesions associated with?
Anterior dislocations
When can Hill-Sachs lesions cause instability?
> 30% of the articular surface may cause instability
What lesions are associated with posterior GHJ dislocations?
– Reverse Bankart lesion
– Reverse Hill–Sachs lesion
What are the symptoms of Dead arm syndrome?
Early shoulder fatigue, pain, numbness, and paresthesia
What causes Dead arm syndrome?
Shoulder slipping in and out of place MC when the arm is placed in the ABD and ER (“throwing position”)
Who most commonly gets Dead arm syndrome?
Athletes such as pitchers or volleyball players who require repetitive overhead arm motion
Describe the apprehension test (shoulder).
Feeling of anterior shoulder instability with 90° shoulder ABD and ER, causing apprehension
*Anterior glenohumeral instability
Describe the relocation test (shoulder).
Supine apprehension test with a posterior-directed force applied to the anterior aspect of the shoulder relieves the feeling of apprehension
*Anterior glenohumeral instability
Describe the anterior drawer test (shoulder).
Passive anterior displacement of the humeral head on the glenoid
*Anterior glenohumeral instability
Describe the anterior load-and-shift test (shoulder).
Humeral head is loaded against the glenoid and then passively displaced anteriorly
*Anterior glenohumeral instability/labrum instability
Describe the jerk test (shoulder).
Arm in 90° of flex and max IR w/ the elbow flex 90°. ADD arm across the body horizontally while pushing the humerus in a posterior direction. Pt jerks away when the arm nears midline to prevent posterior subluxation or dislocation of the humeral head
*Posterior glenohumeral instability
Describe the sulcus sign (shoulder).
Pull down on arm and stabilize scapula, (+) if indentation b/w acromion and humeral head
*Multidirectional glenohumeral instability
Which x-ray view assess glenohumeral dislocations?
Axillary view
Which x-ray view assess Bankart lesions?
West Point lateral axillary
Which x-ray view assess Hill-Sachs lesions?
Stryker notch view
Describe the response to rehab with anterior, posterior and multidirectional GHJ instability.
Anterior: rehab alone insufficient to prevent dislocation
Posterior: rehab adequate
Multi: >80% excellent results with rehab
What is a SLAP lesion?
Superior glenoid Labral tear in the Anterior-to-Posterior direction
What are symptoms of labral tears?
Similar to shoulder instability (clicking, locking, pain)
Describe the O’Brien’s test.
Arm IR, flex, ADD to 15°
Downward force on pronated arm and then supinated arm
(+) if pain improves with supination
What does the O’Brien test detect?
SLAP lesion
What is the most common cause of shoulder pain?
Impingement syndrome
Which tendon is most commonly impinged in the shoulder?
Supraspinatus, under the acromion and the greater tuberosity occurs with arm ABD and IR
Describe stage 1 of subacromial impingement syndrome (Neer).
Edema or hemorrhage—reversible (age <25)
Describe stage 2 of subacromial impingement syndrome (Neer).
Fibrosis and tendonitis (ages 25–40)
Describe stage 3 of subacromial impingement syndrome (Neer).
AC spur and rotator cuff tear (age >40)
Which tendon do rotator cuff tears typically occur?
Supraspinatus
Which part of rotator cuff tendon is prone to injury?
Critical zone of hypovascularity about 1 cm from the insertion site
Describe the types of acromions.
– Type I → Flat
– Type II → Curved
– Type III → Hooked
What activities cause rotator cuff pain?
Repetitive overhead activities
– Throwing a baseball
– Swimming
What stages of swimming cause rotator cuff pain?
Catch phase of overhead swimming
What swimming strokes cause rotator cuff pain?
Freestyle, backstroke, and butterfly
Which tendons are commonly affected together in shoulder?
Supraspinatus and biceps tendon are commonly affected secondary to their location under the acromion
What can indicate a rotator cuff tear?
Inability to initiate abduction
What is the clinical presentation of rotator cuff tears?
– Crepitus, clicking, or catching on overhead activities
– Pain referred along deltoid
– Pain sleeping on affected side
– Weakness in flex, ABD, IR
What can be seen on exam of rotator cuff tears?
– TTP of greater tuberosity or inferior to the acromion
– Atrophy of the involved muscle
Describe Neer’s impingement sign.
Stabilize the scapula and passively forward flex the arm >90°, eliciting pain
What does pain with Neer’s impingement sign indicate?
Supraspinatus tendon is compressing between the acromion and greater tuberosity
Describe Hawkin’s impingement sign.
Stabilize the scapula and passively forward flex (to 90°), then IR arm eliciting pain
What does pain with Hawkin’s impingement sign indicate?
Supraspinatus tendon is compressing against the coracoacromial ligament
Describe the Empty can test.
Pain and weakness with arm flexion abduction and internal rotation (thumb pointed down)
*Rotator cuff
What happens to the humerus with abduction?
Humerus naturally ER
How should the humerus be positioned to assess the supraspinatus?
IR forcing the greater tuberosity under the acromion> max abduction to 120°
Describe the drop arm test.
Passively abducted to 90° and IR
(+) patient unable to maintain abduction w/ or w/o applied force
*Complete rotator cuff tear
How does impingement appear on shoulder x-rays?
Cystic changes in the greater tuberosity
How do chronic rotator cuff tears appear on shoulder x-rays?
■Superior migration of the proximal humerus
■Flattening of the greater tuberosity
■ Subacromial sclerosis
■ Severe superior and medial wear into the glenoid, coracoid, AC joint, and acromion
Describe the Supraspinatus outlet view on x-ray.
15° caudal tilt for a transcapular “Y” view
– Assess acromion morphology
What is the gold standard imaging to assess rotator cuff integrity?
MRI
Gadolinium may be added to evaluate the labrum
What can an arthrogram be useful for in assessing rotator cuffs?
Assessing full thickness tears but unable to delineate the size of the tear or partial tears
How do full thickness rotator cuff tears appear on US?
Nonvisualization of cuff
Discontinuity of cuff
Interposition of the subacromial bursa or deltoid into the vacant tendon
How do partial thickness rotator cuff tears or tendonosis appear on US?
Thickened, heterogeneous appearing tendon, cortical irregularity, or defect in the cuff tendon
Describe the acute phase of rehab for rotator cuff tears/impingement.
■ Relative rest ■ Red pain and inflam ■ US, iontophoresis ■ Restore nonpainful and scapulohumeral ROM ■ Stop muscle atrophy
Describe the recovery phase of rehab for rotator cuff tears/impingement.
■ Proprioception
■ Full pain-free ROM
■ Rotator cuff and scapular stabilizers
■ Assess single planes of motion in activity-related exercises
Describe the functional phase of rehab for rotator cuff tears/impingement.
■ Plyometrics
■ Activity-specific training
■ Swimmers: strengthening the rotator cuff and scapular stabilizers
■ Corticosteroid injection
Describe the surgical procedure for partial thickness rotator cuff tears (<40% thickness).
Partial anterior acromioplasty and coracoacromial ligament lysis (CAL)
Describe the surgical procedure for full thickness rotator cuff tears (>40% thickness).
Excise and repair
What time frame after acute rotator cuff tear has the best functional outcome for surgical repair?
First 3 weeks
What is the most common direction causing shoulder pain from OA?
IR MC but can be with ABD
Describe the views to asses shoulder OA.
- IR, ER and 40° of obliquity
* Axillary view
What are indications for Total shoulder arthroplasty (TSA)?
■ Pain
■ Avascular necrosis
■ Neoplasm
Describe precautions during stage 1 after Total shoulder arthroplasty (TSA).
■ 0 to 6 weeks ■ Avoid active abductions and extension >0° ■ Sling immobilization ■ No ER >15° ■ No active ROM ■ NWB
Describe rehab during stage 1 after Total shoulder arthroplasty (TSA).
■ Gentle PROM (Codman’s exercises)
■ Gentle AROM (wall-walking)
■ Isometrics exercises (progressing)
Describe precautions during stage 2 after Total shoulder arthroplasty (TSA).
6 to 12 weeks
Discontinue sling
Start light weights
Describe rehab during stage 2 after Total shoulder arthroplasty (TSA).
Isotonics
Active-assist ROM (AAROM)
AROM
Describe precautions during stage 3 after Total shoulder arthroplasty (TSA).
> 12 weeks
Previous ROM precautions cancelled
Describe rehab during stage 3 after Total shoulder arthroplasty (TSA).
Start progressive resistive exercises
Active ranging
Stretching
What is the typical patient for a shoulder arthrodesis?
Young heavy laborer with repetitive trauma to the shoulder
What are indications for a shoulder arthrodesis?
■ Severe shoulder pain 2/2 OA
■ Mech loosening of a shoulder arthroplasty
■ Joint infection
What is the fusion position for shoulder arthrodesis?
■ 50° ABD
■ 30° Flex
■ 50° IR
What is seen on x-ray in calcific tendonitis?
Ca deposits, usually at the tendon insertion site
Who typically gets adhesive capsulitis?
MC in women > 40 yo
What disorders are associated with adhesive capsulitis?
– CVA, hemorrhage, brain tumor – Clinical depression – Shoulder–hand syndrome – Parkinson’s disease – Prolonged immobilization – Cervical disc disease – IDDM – Hypothyroidism
Describe the painful stage of adhesive capsulitis.
Progressive vague pain lasting roughly 8 months
Describe the stiffening stage of adhesive capsulitis.
Decreasing ROM lasting roughly 8 months
Describe the thawing stage of adhesive capsulitis.
Increasing ROM with decrease of shoulder pain
Which ROM directions are lost first in adhesive capsulitis?
ER and ABD
When are x-rays indicated in adhesive capsulitis?
R/o underlying tumor or calcium deposit
Pain and motion do not improve after 3 months of treatment
Who is arthroscopic lysis of adhesions reserved for (adhesive capsulitis)?
IDDM who do not respond to manipulation
Where is the origin of the long head of biceps tendon?
Supraglenoid tuberosity
Where is the origin of the short head of biceps tendon?
Apex of the coracoid process
Where is the MC site of rupture of the biceps tendon?
Proximal end of the long head of the biceps tendon
Who is typically affected by biceps tendon rupture?
- > 40 yo w/ chronic impingement syndrome
* Rotator cuff tears in the elderly
Who is typically affected by distal biceps tendon rupture?
Significant physical activities
Bodybuilders
Heavy manual workers
Describe the Yergason’s test.
Pain at the anterior shoulder with flexion of the elbow to 90°, and supination of the wrist against resistance
*Biceps tendonitis
Describe the Speed’s test.
Pain at the anterior shoulder with flexion of the shoulder, elbow extended and supinated against resistance
*Biceps tendonitis
Describe the Ludington’s test.
Pt contract/relax biceps with hands on top of head
(+) contraction of biceps absent on affected side
*Biceps rupture
When is bicep tenodesis indicated?
Younger, active individuals who require heavy lifting
Cosmetic reasons
What is deltoid rupture associated with?
Surgical intervention
Crush injuries
Severe direct blows
When do deltoid strains occur?
Direct blow to the upper arm when it is in abduction and forward flexion
When can the anterior deltoid be injured (throwing)?
Acceleration phase of throwing
When can the posterior deltoid be injured (throwing)?
Deceleration phase of throwing
Describe treatment for deltoid strain and contusion.
Ice and immobilize acutely
Then stretching and progressive strengthening exercises.
Describe treatment for deltoid rupture and avulsion.
Surgical reattachment
What causes medial scapular winging?
– Serratus anterior weakness
– Long thoracic nerve palsy
– Bench pressing very heavy weights or wearing heavy pack straps can also impinge the nerve
What causes lateral scapular winging?
– Trapezius weakness
– Spinal accessory nerve lesions
– Nerve injury occurs in the posterior triangle of the neck
Describe the appearance of medial scapular winging.
Winging of the medial border of the scapula away from the ribs
When is medial scapular winging more evident?
Patient forward flexes the arms or does a wall pushup
Describe the appearance of lateral scapular winging.
Rotary lateral winging of the scapula around the thorax
How can upper trapezius fibers be tested?
Resisted shoulder shrug
How can middle and lower trapezius fibers be tested?
Prone rowing exercise
