Common Shoulder Pathology Flashcards
1
Q
Common shoulder orthopedic impairments
A
- Subacromial rotator cuff impingement
- Glenohumeral instability
- Glenohumeral dislocation: Bankart lesion or Hill-Sachs lesion
- Adhesive capsulitis
- AC joint sprain
- Clavicular fracture
- Humeral fracture
2
Q
Describe primary subacromial rotator cuff impingement
A
- primary impingement = supraspinatus tendinopathy
- possibly poor vascularity: watershed zone
- degeneration of acromion
- mechanical friction with overhead movements
3
Q
Describe secondary subacromial rotator cuff impingement
A
- loss if normal biomechanics: movement along a non-physiological axis
- loss of normal inferior humeral glide with upward humeral rotation (flexion, abduction)
- crowding of supraspinatus tendon under corcoarcromial arch
4
Q
Describe Neer’s 3 stages of subacromial rotator cuff impingement
A
- Stage 1: young (<25 y/o), edema and hemorrhage, & pain with >90 degrees abduction
- Stage 2: age 25-40 y/o, fibrosis, irreversible changes in supraspinatus or bicep tendon, & pain at night, difficulty positioning shoulder for comfort
- Stage 3: operative?, age >40 y/o, tendon degeneration/supraspinatus tears, history of shoulder pain, & muscle weakness/atrophy
5
Q
Rehab priorities for subacromial rotator cuff impingement
A
- scapular stabilization: serratus anterior, middle/lower traps, & levator scapulae
- glenohumeral/scapulothoracic mobilization
- capsular stretches
- activity modification
- modalities for pain & inflammation
6
Q
Describe phase 1 rehab for subacromial impingement
A
- pre-functional phase
- sleeper stretch (posterior capsule)
- self mobilization (lateral distraction & thoracic extension)
- scapular stabilization in physiological axes
- taping/blocking
7
Q
Describe phase 2 and 3 rehab for subacromial impingement
A
- Phase 2: functional return, progression of scapular stabilization & removal of taping/blocking
- Phase 3: functional recovery
8
Q
Describe subacromial decompression (SAD) surgery for subacromial impingement
A
- shaving acromion
- detachment of coracoacromial ligament
- almost always arthroscopic
9
Q
Surgical management for subacromial impingement
A
- activity modification throughout rehab: avoid increased inflammation/delayed recovery
- positioning: sleep and ADLs
10
Q
SAD rehab weeks 0-6
A
- sling 2-7 days, but early mobilization encouraged
- PROM or AAROM to ensure full available range: done daily until full ROM achieved
- posture emphasized or corrected
- scapular stabilization begins: initially below horizontal so as to prevent movement along a non-physiological axis
11
Q
SAD rehab weeks 6-10 and 10-14
A
- once ROM achieved, ensure physiologic movement in available range
- scapulohumeral/scapulothoracic balance
- once scapular stability achieved progress to overhead movement
- pain free ROM with adequate strength
- functional activities/sport-related activities weeks 10-14
12
Q
Describe the MOIs for the different sublet/dislocation of the glenohumeral joint
A
- Anterior sublux/dislocation: shoulder horizontal abduction with external rotation
- Posterior sublux/dislocation: shoulder adducted, internally rotated, and loaded
- Multi-directional instability: congenital laxity or subluxation may be anterior, posterior, or inferior
13
Q
Describe dislocation
A
- complete separation of humeral head from glenoid cavity
- humerus does not spontaneously reduce
14
Q
Describe subluxation
A
- partial separation, results in soft tissue strain at shoulder
- humerus spontaneously reduces
15
Q
Management for subluxation
A
- avoid unstable position
- taping or blocking maybe needed in initial stage
- initial focus on coordination, endurance, & proprioception
16
Q
Management for dislocation
A
- reduced in emergency room or other urgent care environment
- period of protection
- avoid unstable positions
17
Q
Operative management for glenohumeral instability
A
- arthroscopic anterior stabilization surgery
- laxity of capsule is decreased
- rehab begins 1-3 weeks after surgery
- early controlled motion (avoid external rotation and extension)
- goals: restore strength, ROM, flexibility, and propreioception
18
Q
Rehab following anterior stabilization surgery weeks 1-3
A
- immobilizer when not exercising
- external rotation & extension limited to neutral
- flexion/elevation to 90 degrees via AAROM
- scapular stabilization (isometric)
19
Q
Weeks 3-6 rehab following anterior stabilization surgery
A
- external rotation to 45 degrees
- immobilizer discontinued (per surgeon)
- AAROM/wand exercises
- scapular stabilization progressed: no humeral movement
20
Q
Weeks 6-12 rehab following anterior stabilization surgery
A
- full AROM
- progress scapular stabilization with UE movement & weight bearing
- PNF patterns
- functional movements avoiding previously unstable position
21
Q
Weeks 12-18 rehab following anterior stabilization surgery
A
- more sport or activity specific
- plyometrics added
22
Q
Describe a Bankart lesion
A
- avulsion of capsule & glenoid labrum off anterior glenoid rim
- result of traumatic anterior shoulder dislocation
23
Q
Describe a Hill-Sachs lesion
A
- a compression or “impaction fracture” of the posteromedial aspect of the humeral head after anterior shoulder dislocation
24
Q
Describe the 4 types of a labral tear
A
- Type I: degeneration of superior labrum, loss of horizontal abduction with external rotation
- Type II: detachment of labrum & biceps tendon anchor with loss of stability
- Type III: vertical tear of labrum, biceps intact
- Type IV: tear of labrum into biceps tendon
25
Conservative treatment of labral tears
- avoid painful positions PRICEMEM
- scapular stabilization
- closed chain exercises
- coordination of scapulohumeral rhythm
26
Surgical repair of labral tear
- Bankart lesion (from shoulder dislocation): reattachment of torn capsule & labrum to glenoid
- SLAP (superior labral tear from anterior to posterior) lesion repair: debridement of torn labrum & reattachment of labrum & bicep tendon
27
Describe Bankart surgical rehab
- Immobilization 1-8 weeks: maintain hand, wrist, & elbow ROM; CV fitness maintained
- Anterior Bankart repair: avoid anterior dislocation position (i.e external rotation with horizontal abduction)
- Reverse Bankart repair: avoid flexion >90 degrees, horizontal adduction, & internal rotation
28
Describe a SLAP repair rehab
- 0-2 weeks: flexion limited to 60 degrees, ER limited to 15 degrees in neutral, IR limited to 45 degrees in neutral, & pendulum exercises
- 3-4 weeks: flexion limited to 90 degrees, ER limited to 30 degrees & IR to 60 degrees, & wand exercises
- 5-8 weeks: progress to full ROM
- Subacute phase (8-12 weeks post-op): horizontal ABD/ADD, PNF patterns, IR & ER strengthening with arm in protected position (towel roll), & progressive UE weight bearing (hands & knees)
29
Describe adhesive capsulitis (AKA frozen shoulder)
- GH joint hypo mobility due to development of dense adhesions, capsular restrictions, and thickening
- insidious onset b/w 40-60 y/o
- associated with trigger points, guarding of subscapularis
- probably but not conclusively inflammatory
30
Describe primary & secondary adhesive capsulitis
- Primary: idiopathic
- Secondary: systemic origin, extrinsic origin, or intrinsic origin
31
Stages of development of adhesive capsulitis
- Freezing (2-3 weeks); continuous pain including at rest, severe limitation of movement soon after onset
- Frozen (4-12 months): atrophy, pain (although less, & occurring primarily with movement), loss of ROM
- Thawing (12-24+ months): decreased pain, restricted ROM
32
Describe rehab for adhesive capsulitis
- PROM & AAROM in pain free range (physiological axis)
- joint mobilization/self mobilization exercises
- soft tissue massage/trigger point release of subscapularis, upper traps, and levator scapulae
33
Describe AC sprain/dislocation
- direct force to acromion or when force is transmitted proximally to AC from FOOSH
- graded by degree of injury to specific ligamentous structures
34
Degrees of AC sprains/dislocation
- Grade 1: AC joint sprain with minimal loss of function
- Grade 2: AC sprain with moderate pain and some dysfunction
- Grade 3: AC with coracoclavicular ligament injury that may have significant dysfunction
35
Rehab for AC joint sprain grade 1 and 2
- sling 1-2 weeks
- followed by ROM
- once pain free add isometric exercises to the clavicular and scapular muscles
36
Rehab for AC joint sprain grade 3
- acute first 2-4 weeks: physical therapy to decrease pain & swelling and reinforce immobilizer use
- return to function based on pain level & tolerance for activity: ROM and strengthening
37
Describe a clavicle fracture
- 4-15% of all fractures
- 35% of shoulder fractures
- MOI: direct trauma or indirect trauma (FOOSH)
- most are treated non-surgically with sling use for 3-4 weeks
38
ORIF indications for a clavicle fracture
- open fracture
- displaced fractures with impending skin compromise
- neuromuscular compromise
- widely displaced mid-clavicular fractures
- shortening or gross displacement are risk factors for development of a non-union fracture
- sling following surgery for 6 weeks
39
Describe humerus fractures
- 4-5% of all fractures
- increase age = increased incidence
- 85% are minimally displaced
40
What are the 4 typical fragments of a humerus fracture
- humeral head
- greater tuberosity
- lesser tuberosity
- humeral shaft
41
Minimally or non-displaced humeral fracture management
- sling
- early PROM within 14 days (avoid adhesive capsulitis)
- AROM at 4-6 weeks
42
Describe fractures of the humeral neck
- 2 part humerus fracture
- most common displaced humeral fracture
- closed reduction or ORIF
43
Describe fractures of the humerus greater tuberosity
- 2 part humerus fracture
- occur with shoulder dislocation
- ORIF if displaced
44
Describe 3 part humerus fractures management
- ORIF
45
Describe 4 part humerus fractures
- ORIF: young patient and good bone quality
- humeral head replacement: elderly
