Intro to Upper Quarter and Anatomy

Question 1

What area of the Upper Quarter is most commonly injured?

Answer 1

The finger

Question 2

What type of injury is most common in the upper quarter?

Answer 2

Fractures

Question 3

What four basic functions of the shoulder anatomy are most commonly affected by shoulder pathologies?

Answer 3

Mobility
Stability
Smoothness
Strength

Question 4

What is shoulder mobility dysfunction?

What may these restrictions be between?

Answer 4

loss of humerothoracic motion due to passive restrictions

scapula and thorax (scapulothoracic motion)
humerus and scapula (scapulohumeral motion)
combo of the two

Question 5

What type of joint is the sternoclavicular joint?

What is the blood supply and nerve supply of this joint?

Answer 5

synovial saddle joint

Blood Supply-internal thoracic and suprascapular arteries
Nerve Supply- branches of suprascapular nerve and nerve to subclavius

Question 6

what forms the anterior and posterior sternoclavicular ligaments?

Answer 6

thickenings of the fibrous capsule

Question 7

what does the costoclavicular ligament attach to?

Answer 7

attaches the 1st rib and its costal cartilage to the anterior margin of the medial end of the clavicle

Question 8

What type of joint is the acromioclavicular joint?

what ligaments support this joint?

What is the nerve and blood supply of the joint?

Answer 8

planar synovial joint

acromioclavicular lig. (strengthens capsule superiorly) and the coracoclavicular lig. (strengthens lateral end of the clavicle by attaching to clavicle)

Blood Supply-suprascapular and thoracoacromial arteries
Nerve Supply-Lateral pectoral and axillary nerves

Question 9

What are the two parts of the coracoclavicular ligament?

Answer 9

Trapezoid and Conoid

Question 10

What may cause mobility problems for scapulothoracic motion?

Answer 10

• sternoclavicular/acromioclavicular arthritis
• musculotendinous contracture
• rib or scapular fracture
• post traumatic scarring
• tumor
• dislocation

Question 11

What are the three treatment options for painful scapulothoracic structures?

Answer 11

1. modalities and mobilization for pain relief
2. shield structures from abnormal.excessive forces during stretching of G/H joint
3. Restore as much scapulohumeral ROM as possible

Question 12

What type of joint is the glenohumeral joint?

What deepens the joint?

What covers the joint surface?

Answer 12

synovial ball and socket joint

glenoid labrum

hyaline cartilage

Question 13

What are the intrinsic glenohumeral ligaments?

Answer 13

three fibrous bands found only on the internal aspect of the capsule that radiates laterally from the supraglenoid tubercle into three bands (superior, middle and inferior) and they function to strengthen the anterior capsule of the joint

Question 14

What may cause scapulohumeral mobility deficits?

Answer 14

bony and or soft tissues that directly surround the glenohumeral joint or non-articular scapulohumeral motion interface

Question 15

What two categories can generalized capsuloligamentous tightness be divided into?

Answer 15

1. Idiopathic adhesive capsulitis-“primary frozen shoulder” (etiology unknown)
2. Secondary frozen shoulder (etiology secondary to tendinopathy, fracture, post surgery)

Question 16

If the posterior inferior shoulder capsule is tight what motion would be limited?

Answer 16

elevation in anterior planes
internal rotation of elevated arm
cross body adduction

Question 17

If the posterior superior shoulder capsule is tight what motion would be limited?

Answer 17

reach up behind the back

Question 18

If the anterior superior shoulder capsule is tight what motion would be limited?

Answer 18

external rotation with arm at the side

Question 19

If the anterior inferior shoulder capsule is tight what motion would be limited?

Answer 19

external rotation with arm elevated

Question 20

If the anterior shoulder capsule is tight what motion of the humeral head will happen with external rotation?

Answer 20

posterior translation of humeral head (posterior obligate translation)

Question 21

What is capsulorrhaphy arthropathy?

Answer 21

wear of the posterior glenoid and subluxation of humeral head posteriorly

Question 22

What is anterior superior obligate humeral translation?

What patient population is it typically observed in?

Answer 22

tight posterior capsule causes translation of the humeral head anteriorly and superiorly on the glenoid

impingement syndrome patients

Question 23

What are the two parts of the non-articular scapulohumeral motion interface? What comprises of both part?

Answer 23

Deep interface (proximal humerus, rotator cuff, and biceps tendon sheath)

Superficial Interface (deltoid, acromion, coracoacromial ligament, coracoid process and attaching tendons)

Question 24

What can cause stiffness of shoulder joint?

Answer 24

structural changes in periarticular tissues such as shortened capsule, ligaments and muscles that may be accompanied by adhesions and is generally result from combination of trauma and immobilization

non-structural changes in periarticular tissues such as pain, protective muscle spasm, or loose body within the joint

Question 25

What are the two mobilization approaches for shoulder stiffness?

Answer 25

Low-Load Prolonged Stress (LLPS)-via splinting which is more effective in managing structural causes of stiffness High-Load Brief Stress (HLBS)-via mobilization or manipulation of joints and is more effective in managing non-structural causes of stiffness

Question 26

Why might low-load prolonged stress be better than high-load brief stress for anterior superior obligate translation?

Answer 26

with any patient that has a tight capsule end range stretching can produce obligate translation and excessively high joint contact forces

Question 27

What is glenohumeral laxity? What is glenohumeral stability? What is glenohumeral instability?

Answer 27

translation observed on exam of G/H joint ability to maintain humeral head centered in glenoid fossa inability to maintain humeral head centered in glenoid fossa

Question 28

What is glenohumeral apprehension? What is traumatic instability? What is atraumatic instability?

Answer 28

sense of impending instability in certain G/H positions arises from an injury sufficient to tear G/H capsule, labrum, ligaments, rotator cuff or produce fracture of humerus or glenoid arises in absence of significant trauma

Question 29

How does balance in the shoulder joint affect stability?

Answer 29

Glenoid positioned so that the net humeral joint reaction force passes through the glenoid fossa essentially identical humerothoracic positions (90*) achieved using different scapulohumeral positions, which in turn, have different implications for the balance mechanism injury to the glenoid labrum will diminish the glenoid arc length and hence decrease the angular range of stability musculature about the G/H joint plays a big role in maintaining balance stabilizing mechanisms which may fail in cases of muscular imbalance or abnormal glenoid version (glenoid center line deviates substantially from the plane of the scapula)

Question 30

What is concavity compression in the shoulder joint and how does it affect stability?

Answer 30

stability related to the magnitude of compressive force of the rotator cuff Pull of the muscles helps keep the humerus stable (e.g the supraspinatus doesn't pull the humerus downward due to the upward force of the compression from the deltoid) and the cuff muscles act as a "compressor" of head into glenoid concavity

Question 31

What is adhesion-cohesion and how does it increase shoulder stability?

Answer 31

joint surfaces wet with joint fluid are held together by molecular attraction of fluid to itself and to joint surfaces stability is related to adhesive and cohesive properties (viscosity/stickiness) of joint fluid, wetability of joint surfaces, and area of contact b/w glenoid socket and humerus

Question 32

What is the syringe effect?

Answer 32

the GH joint is a closed space with minimal free fluid and is not easily distracted, movement is restricted by the negative fluid pressure which also adds resistance to distraction by drawing capsule inwards and tightening fibers

Question 33

How does capsuloligamentous constraint affect shoulder stability?

Answer 33

- serve as "check reigns" at limits of G/H motion-translation and rotation - capsule and ligaments not "primary stabilizers"-cannot effectively hold humeral head centered in glenoid socket in most functional positions of joint

Question 34

What controls the maximal scapulohumeral angle that can be achieved in a given direction? What limits cross body adduction?

Answer 34

Capsule and ligaments posterior capsule

Question 35

Which ligament checks ROM of shoulder joint when the arm is elevated and forced into ER?

Answer 35

Inferior glenoid humeral ligament

Question 36

What tests can be done to test shoulder stability/instability?

Answer 36

- sulcus sign - apprehension test - relocation test - O'brien's active compression test - Anterior slide test - Load and shift test - Crank Test

Question 37

How do subluxation and dislocation occur and affect glenohumeral instability?

Answer 37

Subluxation results from an increased humeral head translation on the glenoid. The head moves partially off the glenoid rim and quickly repositions itself Dislocation occurs when the humeral head moves off the glenoid rim and may require manipulation to be reduced

Question 38

What are the different types of instability?

Answer 38

``` congenital acute chronic recurrent traumatic atraumatic voluntary ```

Question 39

What are the two groups of glenohumeral instability?

Answer 39

TUBS (torn loose)- traumatic, unidirectional, bankart, surgery AMBRII (born loose)- Atraumatic (or microtraumatic), multidirectional, bilateral, rehab, inferior capsular shift, rotator interval

Question 40

Which group of glenohumeral instability usually needs medical assistance to reduce? Which instability group will usually have negative X-rays?

Answer 40

TUBS (AMBRII reduces spontaneously) AMBRII (Bankart and Hills-Sachs will show up on X-rays in TUBS group)

Question 41

What is the most common direction of instability in the shoulder? What type of instability can be caused from seizures, shock, or falling on a flexed/adducted arm?

Answer 41

Anterior instability (for Abduction/ER mechanism) 97% of recurrent dislocations Posterior instability (FOOSH)

Question 42

What is a bankart lesion?

Answer 42

detachment of the anterior glenoid labrum

Question 43

What is a Hills-Sachs Lesion?

Answer 43

When postero-superior aspect of the humeral head sustains a compression fracture or depression defect

Question 44

What is the typical pathology of an anterior dislocation/subluxation?

Answer 44

traction injury of the brachial plexus and axillary blood vessels can occur with a dislocation (nerve injury can happen to any brachial plexus nerve)

Question 45

What is the most common sequela of traumatic anterior shoulder instability? What is a common complication of traumatic anterior shoulder instability in patients over 40?

Answer 45

recurrence, which will happen with 90% of those between the ages of 11 and 20 neurologic injury and rotator cuff tears

Question 46

True or false: length of immobilization, avoidance of overhead activity, and supervised PT has no effect on the outcome of reccurence of anterior shoulder instability

Answer 46

True

Question 47

What are the 5 areas of smoothness in the shoulder complex?

Answer 47

``` G/H Joint S/C Joint A/C Joint Scapulothoracic motion interface Scapulohumeral motion interface ```

Question 48

What causes loss of smoothness in the shoulder joint?

Answer 48

infammatory joint disease, avascular necrosis, tumor, or osteomyelitis, as well as labral tears or loose bodies

Question 49

What is the most common injury to the shoulder? What does it usually involve?

Answer 49

Supraspinatus Tendinitus usually involves avascular zone of the tendon and may include synovial irritation (bursa and capsule), micro or macro tears

Question 50

What motion may be most painful in a patient suffering from infraspinatus tendinitis?

Answer 50

Ext. Rotation

Question 51

What signs during the subjective history exam would be common in patients with shoulder tendinits?

Answer 51

- anterolateral shoulder pain, especially with reaching or lifting overhead - onset may involve trauma, overuse, or gradual overload of the cuff - pain may be greater at night when arm is by the side or overhead (wringing out phenomena-avascular zone)

Question 52

What are the physical signs and symptoms of shoulder tendinitis?

Answer 52

- AROM may display decreased motion or a painful arc - PROM may be painfree (contractile lesion) - Resistive may be painful in the primary motion of the involved structure - Mobility testing normal unless there are long term capsular changes

Question 53

What common muscle imbalances may be present in a patient with shoulder tendinitis? What faulty movement patterns would be observed?

Answer 53

Tight: levator, upper trap, pec major/minor, lats, SCM, and scalenes Weak: Middle/lower trap, serratus, rhomboids, deltoid, deep neck flexors Abnormal scapulo-humeral rhythm in a 1:1 ratio, winging, increased scapular protraction and elevation with initial downward rotation

Question 54

What is bicipital tendinitis/tenosynovitis? How common is it?

Answer 54

inflammation of the biceps tendon in the bicipital groove or inside the capsule present in 1/7 RC lesions

Question 55

What is impingement Syndrome? What does it lead to?

Answer 55

repetitive compressive loads on structures in the suprahumeral space which lead to inadequate inferior glide with elevation leads to "impingement" leads to tendinitis and/or bursitis. Most patients will have inflammation of both structures as both are impinged-may culminate in a rotator cuff tear

Question 56

What are the intrinsic causes of impingement syndrome?

Answer 56

- degenerative tendinopathy - muscle weakness may cause superior humeral glide wi/ movement - overuse - laxity anteriorly w/ a tight posterior capsule can lead to secondary or internal impingement - hypovascular area: Codman's "critical zone" of the supraspinatus tendon where most degenerative changes occur

Question 57

What can cause weakness in the shoulder joint?

Answer 57

``` full/partial thickness tears C-spine radiculopathy Long thoracic nerve palsy Suprascapular neuropathy Axillary nerve trauma Scapulohumeral muscular dystrophy ```

Question 58

What is the most common cause of rotator cuff tears?

Answer 58

impingement wear and attrition

Question 59

What are the 3 progressive stages of impingement?

Answer 59

Stage 1: less than 25 y.o w/ acute inflammation, edema and homorrhage in rotator cuff, reversible and non-operative Stage 2: 25-40 years w/ progression from acute edema and hemorrhage to fibrosis and tendinitis of rotator cuff, usually responds to conservative management Stage 3: 40+ years w/ mechanical disruption of tendons (tears) and osteophytes under acromion, thickening of coracoacromial arch, more likely to require surgery

Question 60

What are the 3 common sites of tears in rotator cuff and which is most common?

Answer 60

Bursal Side Articular Side (most common) Midsubstance

Question 61

What is the notch phenomenon?

Answer 61

the stress on the tendon is channeled toward the edges of the defect, leading to further fiber failure

Question 62

What is the natrual progression of rotator cuff tears?

Answer 62

- starts as a partial thickness tear secondary to tendon overload - poor healing potential and progression of tear due to hostile environment - rotator cuff insufficiency due to pain and inhibition - superior migration of humeral head and increased contact forces in subacromial space - degenerative chanes in under surface of subacromial space - impingement syndrome and progression to full thickness tear - degenerative joint disease "cuff tear arthropathy"

Question 63

What is "cuff tear arthropathy"?

Answer 63

When X-rays show an 'acetabularization' of upper glenoid and coracoacromia arch, and 'femorilzation' of proximal humerus

Question 64

What are the indications for total shoulder replacement?

Answer 64

- Shoulder joint pain from destructive arthritis secondary to OA, RA, or traumatic arthritis - Avascular Necrosis - Severe loss of upper extremity strength - Limitations of ADL function secondary to pain