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BR 3rd Ed > Ch 4 - MSK: Shoulder > Flashcards

Ch 4 - MSK: Shoulder Flashcards

1
Q

Describe normal ROM of the shoulder

A 
• Flexion: 180° 
• Extension: 60° 
• Abduction: 180°
 – 120° w/ thumb down 
• Adduction: 60° 
• IR: 90° (w/ arm ABD) 
• ER: 90° (w/ arm ABD)
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2
Q

Describe muscles and innervation involved with shoulder flexion.

A
  • Anterior deltoid (axillary n, posterior cord: C5, C6)
  • Pectoralis major, clavicular portion (medial and lateral pectoral nerves: C5, C6, C7, C8, T1)
  • Biceps brachii (musculocutaneous n, lateral cord: C5, C6)
  • Coracobrachialis (musculocutaneous n, lateral cord: C5, C6)
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3
Q

Describe muscles and innervation involved with shoulder extension.

A
  • Posterior deltoid (axillary n, posterior cord: C5, C6)
  • Lat (thoracodorsal n, posterior cord: C6, C7, C8)
  • Teres major (lower subscapular n, posterior cord: C5, C6)
  • Triceps, long head (radial n, posterior cord: C6, C7, C8)
  • Pec major, sternocostal portion (medial and lateral pectoral nerves: C5, C6, C7, C8, T1)
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4
Q

Describe muscles and innervation involved with shoulder ABDuction.

A
  • Middle deltoid (axillary n, posterior cord: C5, C6)

* Supraspinatus (suprascapular n, upper trunk: C5, C6)

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5
Q

Describe muscles and innervation involved with shoulder ADDuction.

A
  • Pec major (medial and lateral pectoral nerves: C5, C6, C7, C8, T1)
  • Lat (thoracodorsal n, posterior cord: C6, C7, C8)
  • Teres major (lower subscapular n, posterior cord: C5, C6)
  • Coracobrachialis (musculocutaneous n, lateral cord: C5, C6, C7)
  • Infraspinatus (suprascapular n, upper trunk: C5, C6)
  • Long head of triceps (radial n, posterior cord: C6, C7, C8)
  • Anterior and posterior deltoid (axillary n, posterior cord: C5, C6)
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6
Q

Describe muscles and innervation involved with shoulder internal rotation.

A
  • Subscapularis (upper and lower subscapular n, posterior cord: C5, C6)
  • Pec major (medial and lateral pectoral n: C5, C6, C7, C8, T1)
  • Lat (thoracodorsal n, posterior cord: C5, C6)
  • Anterior deltoid (axillary n, posterior cord: C5, C6)
  • Teres major (lower subscapular n, posterior cord: C5, C6
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7
Q

Describe muscles and innervation involved with shoulder external rotation.

A
  • Infraspinatus (suprascapular n, upper trunk: C5, C6)
  • Teres minor (axillary n, posterior cord: C5, C6)
  • Deltoid, posterior portion (axillary n, posterior cord: C5, C6)
  • Supraspinatus (suprascapular n, upper trunk: C5, C6)
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8
Q

How is arm abduction achieved?

A

Glenohumeral and scapulothoracic joint motion

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9
Q

There are _____ for every ____ during arm abduction

A

2 degrees glenohumeral motion for ever 1 degree of scapulothoracic motion

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10
Q

What does scapulothoracic motion allow?

A

Glenoid to rotate and permits glenohumeral abduction without acromial impingement

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11
Q

What % of the humeral head articulates with the glenoid fossa?

A

30%

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12
Q

What does the labrum prevent?

A

Anterior and posterior humeral head dislocation

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13
Q

What % does the labrum increase humeral contact with the glenoid?

A

70%

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14
Q

What is the purpose the superior glenohumeral ligament?

A

– Prevents inferior translation

– Provides stability from 0° to 90° of abduction with middle GHL

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15
Q

What is the purpose the middle glenohumeral ligament?

A

Prevents anterior shoulder translation

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16
Q

What is the purpose the inferior glenohumeral ligament?

A

Primary anterior ligament stabilizer above 90°

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17
Q

What are the dynamic stabilizers of the shoulder?

A
  • Rotator cuff muscles
  • Long head of the biceps tendon
  • Deltoid
  • Teres major
  • Latissimus dorsi
  • Scapular stabilizers
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18
Q

What are the static stabilizers of the shoulder?

A

Glenoid
Labrum
Capsule
Glenohumeral ligament

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19
Q

What are the ligaments of the AC joint?

A

AC ligament
Coracoclavicular ligament
Coracoacromial ligament

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20
Q

What does the AC ligament provide?

A

Horizontal stability

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21
Q

What does the CC ligament prevent?

A

Prevents vertical translation of the clavicle

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22
Q

Describe a type I AC separation.

A

Clavicle not elevated
AC lig: mild sprain
CC lig: intact

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23
Q

Describe a type II AC separation.

A 
Clavicle  not above the superior border of the acromion
AC lig: ruptured
CC lig: sprain
joint capsule: ruptured
deltoid: min detached
trapezius: min detached
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24
Q

Describe a type III AC separation.

A 
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
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25
Q

Describe a type IV AC separation.

A 
Posterior and superior into the trapezius, giving a buttonhole appearance
AC lig: ruptured
CC lig: ruptured
joint capsule: ruptured
deltoid: detached
trapezius: detached
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26
Q

Describe a type V AC separation.

A 
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
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27
Q

Describe a type VI AC separation.

A 
Clavicle inferiorly displaced behind coracobrachialis and biceps tendons, which is rare
AC lig: ruptured
CC lig: ruptured
joint capsule: ruptured
deltoid: detached
trapezius: detached
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28
Q

Describe the Cross-chest (horizontal adduction or scarf) test.

A

Passive adduction of the arm across the midline causing joint tenderness

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29
Q

What type of x-rays should be done fo AC separation?

A

Weighted anterior-posterior (AP) radiographs of the shoulders (10 lb)

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30
Q

What is seen on radiographs in a type III and V AC separation?

A

– Type III: 25% to 100% widening of the clavicular–coracoid area
– Type V: widening >100%

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31
Q

Describe treatment for a Type I and II AC separation.

A

– 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

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32
Q

Describe treatment for a Type III AC separation.

A

Surgical for those indicated (heavy laborers, athletes)

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33
Q

Describe treatment for a Type IV, V and VI AC separation.

A

ORIF or distal clavicular resection with reconstruction of the CC ligament

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34
Q

What are complications of AC joint injuries?

A
  • Clavicular fxs and dislocations
  • Distal clavicle osteolysis
  • AC joint arthritisrehabilitative care
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35
Q

What is Distal clavicle osteolysis?

A

Degeneration of the distal clavicle with associated osteopenia and cystic changes

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36
Q

What is GHJ instability?

A

Translation of the humeral head on the glenoid fossa

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37
Q

What is GHJ subluxation?

A

Incomplete separation of the humeral head from the glenoid fossa with immediate reduction

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38
Q

What is GHJ dislocation?

A

Complete separation of the humeral head from the glenoid fossa without immediate reduction

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39
Q

What is the most common direction of GHJ instability?

A

Anterior inferior

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40
Q

What is the mechanism of anterior GHJ instability?

A

Arm abduction and ER

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41
Q

Who most commonly has anterior GHJ instability?

A

Younger population and has a high recurrence rate

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42
Q

What are complications of anterior GHJ instability?

A

Axillary never injury

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43
Q

What is the mechanism of posterior GHJ instability?

A

Landing on a forward flexed ADDucted arm

Seizures

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44
Q

How does a patient with posterior GHJ instability present?

A

Arm ADDucted and IR position

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45
Q

What are traumatic patterns of GHJ instability?

A 
"T.U.B.S."
T - Traumatic shoulder instability 
U - Unidirectional 
B - Bankart lesion 
S - Surgical management
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46
Q

What are atraumatic patterns of GHJ instability?

A 
"A.M.B.R.I."
A - Atraumatic shoulder instability 
M - Multidirectional instability 
B - Bilateral lesions 
R - Rehabilitation management 
I - Inferior capsular shift, if surgery
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47
Q

Describe a Bankart lesion.

A

Labral tear off the anterior glenoid allows the humeral head to slip anteriorly and may be associated with avulsion fx off glenoid rim

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48
Q

What direction of GHJ dislocation are Bankart lesions associated with?

A

Anterior dislocations

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49
Q

Describe a Hill-Sachs lesion.

A

Compression fracture of the posterolateral humeral head caused by abutment against the anterior rim of the glenoid fossa

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50
Q

What direction of GHJ dislocation are Hill-Sachs lesions associated with?

A

Anterior dislocations

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51
Q

When can Hill-Sachs lesions cause instability?

A

> 30% of the articular surface may cause instability

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52
Q

What lesions are associated with posterior GHJ dislocations?

A

– Reverse Bankart lesion

– Reverse Hill–Sachs lesion

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53
Q

What are the symptoms of Dead arm syndrome?

A

Early shoulder fatigue, pain, numbness, and paresthesia

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54
Q

What causes Dead arm syndrome?

A

Shoulder slipping in and out of place MC when the arm is placed in the ABD and ER (“throwing position”

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55
Q

Who most commonly gets Dead arm syndrome?

A

Athletes such as pitchers or volleyball players who require repetitive overhead arm motion

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56
Q

Describe the apprehension test.

A

Feeling of anterior shoulder instability with 90° shoulder ABD and ER, causing apprehension

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57
Q

Describe the relocation test.

A

Supine apprehension test with a posterior-directed force applied to the anterior aspect of the shoulder relieves the feeling of apprehension

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58
Q

Describe the anterior drawer test.

A

Passive anterior displacement of the humeral head on the glenoid

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59
Q

Describe the anterior load-and-shift test.

A

Humeral head is loaded against the glenoid and then passively displaced anteriorly

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60
Q

Describe the jerk test.

A

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

61
Q

Describe the sulcus sign.

A

Pull down on arm and stabilize scapula, (+) if indentation b/w acromion and humeral head

62
Q

Which x-ray view assess glenohumeral dislocations?

A

Axillary view

63
Q

Which x-ray view assess Bankart lesions?

A

West Point lateral axillary

64
Q

Which x-ray view assess Hill-Sachs lesions?

A

Stryker notch view

65
Q

Describe the response to rehab with anterior, posterior and multidirectional GHJ instability.

A

Anterior: rehab alone insufficient to prevent dislocation
Posterior: rehab adequate
Multi: >80% excellent results with rehab

66
Q

What is a SLAP lesion?

A

Superior glenoid Labral tear in the Anterior-to-Posterior direction

67
Q

What are symptoms of labral tears?

A

Similar to shoulder instability (clicking, locking, pain)

68
Q

Describe the O’Brien’s test.

A

Arm IR, flex, ADD to 15°
Downward force on pronated arm and then supinated arm
(+) if pain improves with supination

69
Q

What does the O’Brien test detect?

A

SLAP lesion

70
Q

What is the most common cause of shoulder pain?

A

Impingement syndrome

71
Q

Which tendon is most commonly impinged?

A

Supraspinatus, under the acromion and the greater tuberosity occurs with arm ABD and IR

72
Q

Describe stage 1 of subacromial impingement syndrome (Neer).

A

Edema or hemorrhage—reversible (age <25)

73
Q

Describe stage 2 of subacromial impingement syndrome (Neer).

A

Fibrosis and tendonitis (ages 25–40)

74
Q

Describe stage 3 of subacromial impingement syndrome (Neer).

A

AC spur and rotator cuff tear (age >40)

75
Q

Which tendon do rotator cuff tears typically occur?

A

Supraspinatus

76
Q

Which part of rotator cuff tendon is prone to injury?

A

Critical zone of hypovascularity about 1 cm from the insertion site

77
Q

Describe the types of acromions.

A

– Type I → Flat
– Type II → Curved
– Type III → Hooked

78
Q

What activities cause rotator cuff pain?

A

Repetitive overhead activities
– Throwing a baseball
–Swimming

79
Q

What stages of swimming cause rotator cuff pain?

A

Catch phase of overhead swimming

80
Q

What swimming strokes cause rotator cuff pain?

A

Freestyle, backstroke, and butterfly

81
Q

Which tendons are commonly affected together?

A

Supraspinatus and biceps tendon are commonly affected secondary to their location under the acromion

82
Q

What can indicate a rotator cuff tear?

A

Inability to initiate abduction

83
Q

What is the clinical presentation of rotator cuff tears?

A

– Crepitus, clicking, or catching on overhead activities
– Pain referred along deltoid
– Pain sleeping on affected side
– Weakness in flex, ABD, IR

84
Q

What can be seen on exam of rotator cuff tears?

A

– TTP of greater tuberosity or inferior to the acromion

– Atrophy of the involved muscle

85
Q

Describe Neer’s impingement sign.

A

Stabilize the scapula and passively forward flex the arm >90°, eliciting pain

86
Q

What does pain with Neer’s impingement sign indicate?

A

Supraspinatus tendon is compressing between the acromion and greater tuberosity

87
Q

Describe Hawkin’s impingement sign.

A

Stabilize the scapula and passively forward flex (to 90°) the IR arm eliciting pain

88
Q

What does pain with Hawkin’s impingement sign indicate?

A

Supraspinatus tendon is compressing against the coracoacromial ligament

89
Q

Describe the Empty can test.

A

Pain and weakness with arm flexion abduction and internal rotation (thumb pointed down)

90
Q

What happens to the humerus with abduction?

A

Humerus naturally ER

91
Q

How should the humerus be positioned to assess the supraspinatus?

A

IR forcing the greater tuberosity under the acromion> max abduction to 120°

92
Q

Describe the drop arm test.

A

Passively abducted to 90° and IR

(+) patient unable to maintain abduction w/ or w/o applied force

93
Q

How does impingement appear on shoulder x-rays?

A

Cystic changes in the greater tuberosity

94
Q

How do chronic rotator cuff tears impingement appear on shoulder x-rays?

A

■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

95
Q

Describe the Supraspinatus outlet view on x-ray.

A

15° caudal tilt for a transcapular “Y” view

– Assess acromion morphology

96
Q

What is the gold standard imaging to assess rotator cuff inegrity?

A

MRI

Gadolinium may be added to evaluate the labrum

97
Q

What can an arthrogram be useful for in assessing rotator cuffs?

A

Sssessing full thickness tears but unable to delineate the size of the tear or partial tears

98
Q

How do full thickness rotator cuff tears appear on US?

A

Nonvisualization of cuff
Discontinuity of cuff
Interposition of the subacromial bursa or deltoid into the vacant tendon

99
Q

How do partial thickness rotator cuff tears or tendonosis appear on US?

A

Thickened, heterogeneous appearing tendon, cortical irregularity, or defect in the cuff tendon

100
Q

Describe the acute phase of rehab for rotator cuff tears/impingement.

A 
■ Relative rest
■ Red pain and inflam
■ US, iontophoresis
■ Restore nonpainful and scapulohumeral ROM
■ Stop muscle atrophy
101
Q

Describe the recovery phase of rehab for rotator cuff tears/impingement.

A

■ Proprioception
■ Full pain-free ROM
■ Rotator cuff and scapular stabilizers
■ Assess single planes of motion in activity-related exercises

102
Q

Describe the functional phase of rehab for rotator cuff tears/impingement.

A

■ Plyometrics
■ Activity-specific training
■ Swimmers: strengthening the rotator cuff and scapular stabilizers
■ Corticosteroid injection

103
Q

Describe the surgical procedure for partial thickness rotator cuff tears (<40% thickness).

A

Partial anterior acromioplasty and coracoacromial ligament lysis (CAL)

104
Q

Describe the surgical procedure for full thickness rotator cuff tears (>40% thickness).

A

Excise and repair

105
Q

What time frame after acute rotator cuff tear has the best functional outcome for surgical repair?

A

First 3 weeks

106
Q

What is the most common direction of causing shoulder pain from OA?

A

IR MC but can be with ABD

107
Q

Describe the views to asses shoulder OA.

A
  • IR, ER and 40° of obliquity

* Axillary view

108
Q

What are inidcations for Total shoulder arthroplasty (TSA)?

A

■ Pain
■ Avascular necrosis
■ Neoplasm

109
Q

Describe precautions during stage 1 after Total shoulder arthroplasty (TSA).

A 
■ 0 to 6 weeks
■ Avoid active abductions and extension >0°
■ Sling immobilization
■ No ER >15°
■ No active ROM
■ NWB
110
Q

Describe rehab during stage 1 after Total shoulder arthroplasty (TSA).

A

■ Gentle PROM (Codman’s exercises)
■ Gentle AROM (wall-walking)
■ Isometrics exercises (progressing)

111
Q

Describe precautions during stage 2 after Total shoulder arthroplasty (TSA).

A

6 to 12 weeks
Discontinue sling
Start light weights

112
Q

Describe rehab during stage 2 after Total shoulder arthroplasty (TSA).

A

Isotonics
Active-assist ROM (AAROM)
AROM

113
Q

Describe precautions during stage 3 after Total shoulder arthroplasty (TSA).

A

> 12 weeks

Previous ROM precautions cancelled

114
Q

Describe rehab during stage 3 after Total shoulder arthroplasty (TSA).

A

Start progressive resistive exercises
Active ranging
Stretching

115
Q

What is the typical patient for a shoulder arthrodesis?

A

Young heavy laborer with repetitive trauma to the shoulder

116
Q

What are indications for a shoulder arthrodesis?

A

■ Severe shoulder pain 2/2 OA
■ Mech loosening of a shoulder arthroplasty
■ Joint infection

117
Q

What is the fusion position for shoulder arthrodesis?

A

■ 50° ABD
■ 30° Flex
■ 50° IR

118
Q

What is seen on x-ray in calcific tendonitis?

A

Ca deposits, usually at the tendon insertion site

119
Q

Who typically gets adhesive capsulitis?

A

MC in women > 40 yo

120
Q

What disorders are associated with adhesive capsulitis?

A 
– CVA, hemorrhage, brain tumor
 – Clinical depression
 – Shoulder–hand syndrome
 – Parkinson’s disease 
–Prolonged immobilization
 – Cervical disc disease
 – IDDM
 – Hypothyroidism
121
Q

Describe the painful stage of adhesive capsulitis.

A

Progressive vague pain lasting roughly 8 months

122
Q

Describe the stiffening stage of adhesive capsulitis.

A

Decreasing ROM lasting roughly 8 months

123
Q

Describe the thawing stage of adhesive capsulitis.

A

Increasing ROM with decrease of shoulder pain

124
Q

Which ROM directions are lost first in adhesive capsulitis?

A

ER and ABD

125
Q

When are x-rays indicated in adhesive capsulitis?

A

R/o underlying tumor or calcium deposit

Pain and motion do not improve after 3 months of treatment

126
Q

Who is arthroscopic lysis of adhesions reserved for?

A

IDDM who do not respond to manipulation

127
Q

Where is the origin of the long head of biceps tendon?

A

Supraglenoid tuberosity

128
Q

Where is the origin of the short head of biceps tendon?

A

Apex of the coracoid process

129
Q

Where is the MC site of rupture of the biceps tendon?

A

Proximal end of the long head of the biceps tendon

130
Q

Who is typically affected by biceps tendon rupture?

A
  • > 40 yo w/ chronic impingement syndrome

* Rotator cuff tears in the elderly

131
Q

Who is typically affected by distal biceps tendon rupture?

A

Significant physical activities
Bodybuilders
Heavy manual workers

132
Q

Describe the Yergason’s test.

A

Pain at the anterior shoulder with flexion of the elbow to 90°, and supination of the wrist against resistance

133
Q

Describe the Speed’s test.

A

Pain at the anterior shoulder with flexion of the shoulder, elbow extended and supinated against resistance

134
Q

Describe the Ludington’’s test.

A

Pt contract/relax biceps with hands on top of head

(+) contraction of biceps absent on affected side

135
Q

When is bicep tenodesis indicated?

A

Younger, active individuals who require heavy lifting

Cosmetic reasons

136
Q

What is deltoid rupture associated with?

A

Surgical intervention
Crush injuries
Severe direct blows

137
Q

When do deltoid strains occur?

A

Direct blow to the upper arm when it is in abduction and forward flexion

138
Q

When can the anterior deltoid be injured?

A

Acceleration phase of throwing

139
Q

When can the posterior deltoid be injured?

A

Deceleration phase of throwing

140
Q

Describe treatment for deltoid strain and contusion.

A

Ice and immobilize acutely

Then stretching and progressive strengthening exercises.

141
Q

Describe treatment for deltoid rupture and avulsion.

A

Surgical reattachment

142
Q

What causes medial scapular winging?

A

– Serratus anterior weakness
– Long thoracic nerve palsy
– Bench pressing very heavy weights or wearing heavy pack straps can also impinge the nerve

143
Q

What causes lateral scapular winging?

A

– Trapezius weakness
– Spinal accessory nerve lesions
– Nerve injury occurs in the posterior triangle of the neck

144
Q

Describe the appearance of medial scapular winging.

A

Winging of the medial border of the scapula away from the ribs

145
Q

When is medial scapular winging more evident?

A

Patient forward flexes the arms or does a wall pushup

146
Q

Describe the appearance of lateral scapular winging.

A

Rotary lateral winging of the scapula around the thorax

147
Q

How can upper trapezius fibers be tested?

A

Resisted shoulder shrug

148
Q

How can middle and lower trapezius fibers be tested?

A

Prone rowing exercise

BR 3rd Ed (92 decks)

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