Lecture 1 - The shoulder Flashcards
What are the joints that make up the shoulder girdle
Acromioclavicular - planar synovial joint between acromion of the scapula and the clavicle
Sternoclavicular - planar synovial joint between the medial clavicle and the superolateral manubrium
Scapulothoracic - articulation between anterior surface of the scapula and posterior thoracic cage (not synovial joint)
Glenohumeral - synovial ball and socket joint between glenoid fossa of scapula and head of humerus
Describe the subacromial bursa
From deltoid to coracoacromial arch superiorly and rotator cuff inferiorly
Well vascularised
Has proprioceptive and nociceptive nerve endings
What are the two key muscles for scapula movement and describe what they do
Trapezius:
Lower fibres - upward rotation, retraction and depression
Upper fibres - upward rotation, retraction and elevation
Serratus anterior:
Upwardly rotates and protracts the scapula
What happens if trapezius is deinnervated
The scapula doesn’t upwardly rotate or elevate
This means the action of serratus anterior is uncoupled so the scapula is very protracted
What happens if serratus anterior is deinnervated
The scapula experiences ‘winging’ where the medial border is highly pronounced as protraction isn’t performed
What different forces pull on the humeral head and in what direction?
Deltoid - upward force
Long head of biceps tendon - downward force
Rotator cuff - counteracts upward force of the deltoid and medial force orientates humeral head on the glenoid
Give some contributors to shoulder instability
Rotator cuff weakness
Inefficiency of coracohumeral or glenohumeral ligaments
Trapezius of serratus anterior efficiency impacting scapular control
What are the limits to anterior translation
Posterior rotator cuff (teres minor and infraspinatus)
Anterior inferior glenohumeral ligament - abduction and lateral rotation tighten the ligament which squeezes the humeral head posteriorly
Secondary contributors = global cuff, long head of biceps, anterior capsule, middle and superior GHL and coracohumeral ligament
What are the limits to posterior translation
Anterior rotator cuff (subscapularis)
Posterior inferior glenohumeral ligament - horizontal adduction and medial rotation tighten these ligaments
Secondary contributors = global cuff and posterior capsule
What are the sporting causes of anterior and posterior instability
Anterior - bowlers, tennis (shoulder is extended and externally rotated)
Posterior - cycling, windsurfing (sports where forces go through arms in a downward direction) - also falling with arms outstretched
What might patients with shoulder instability report in their history
Dull ache
Apprehension - described as ‘feels not quite right’
Family history likely
Pain at night on either side
Dead arm syndrome (anterior)
What are the limits to inferior translation
Superior portion of rotator cuff (supraspinatus) or global cuff weakness
Superior and inferior GHL, coracohumeral ligament and joint capsule
Negative intra-articular pressureP
Describe the relevance of negative intra-articular pressure in the glenohumeral joint
Pressure is greater outside the joint compared to the inside helping to stabilise the humeral head, if the pressure becomes balanced due to the capsule being compromised, less force is required to translate the humeral head
Describe dead arm syndrome and why it happens
In a position of abduction and external rotation the humeral head falls forward due to anterior instability and applies downward pressure on the brachial plexus
This causes a sudden uncomfortable, electric feeling that will lead the person to drop what they are holding and furiously rub their shoulder
Describe how you do the anterior apprehension and relocation test
Apply anterior glide to the humeral head
Flex the elbow to 90 degrees and externally rotate the shoulder
Take the shoulder through points of the range of abduction (bring back and forth because bringing it through the full range of abduction is painful)
Positive result is apprehension or pain between 90 and 130
Repeat with a posterior glide
Positive test is reinforced if symptoms are removed
Describe how you would do the jerk test for posterior instability
Have the patient in supine with the elbow flexed to 90 degrees and shoulder flexed 90 degrees in scapula plane
Examiner has one hand round the back of the humerus with pinky directly under the humeral head
Push down on elbow through your naval
A positive is a jerk as the humerus displaces off the glenoid (or if more subtle, increased posterior movements of the humerus compared to the other side)
Describe how you would complete a sulcus sign test for multidirectional instability
The patient can be standing or sitting with their arm by their side, the examiner holds the epicondyle and applies a downward traction like force
A positive is if the sulcus appears larger than a single finger (the patient’s) below the acromion
Describe the 5 principles of treatment of shoulder issues
- Pain management
- Correct joint and soft tissue mobility
- Correct muscle strength, endurance and recruitment
- Establish functional patterns of movement
- Reinforce effective patterns of movement
What is shoulder impingement?
Symptoms of pain and dysfunction resulting from any pathology which either decreases the size of the subacromial space or increases the size of its contents
What are the three categories of classification for shoulder impingement?
Primary
Secondary
Primary inflammatory/degenerative changes
Give some primary causes of shoulder impingement
Osteophytes
Calcific bursa/tendon
Fracture
A-C joint dislocation
OA/RA of acromioclavicular joint
Shape/morphology of the acromion
Give some secondary causes of shoulder impingement
Posture
Weakness
Ergonomics
Neuropathy
Muscle imbalance
How does a weak rotator cuff lead to impingement
Weak rotator cuff leads to humeral head superior translation which makes the subacromial space smaller
Give some causes of shoulder impingement related to primary inflammatory/degenerative changes
Tendinitis/osis
Bursitis
Capsulitis
Synovitis
Rotator cuff tears
What borders the subacromial space
Between coraco-acromial arch and humeral head/greater tuberosity of the humerus
What are the contents of the subacromial space?
Shoulder joint capsule
Rotator cuff tendons
Long head of biceps tendon
Subacromial bursa
Glenohumeral and coraco-humeral ligaments
What might you expect to learn from a subjective assessment with a patient with shoulder impingement
> 45
Usually gradual onset due to repetitive overuse
Repetitive use in positions of abduction/flexion i.e. gardening, decorating, moving house
Pain putting on coat, reaching for things etc
Pain lying on affected side
If severe pain can spread from arm to hand
How would you perform a painful arc test?
Abduct the arm in the scapular pain
Pain between 60 and 120 degrees indicates rotator cuff tendon irritation
How would you perform an empty can test?
The patient actively abducts the arm to 90 degrees in scapular plane with thumb facing downward and examiner applies downward resistance, the test is then repeated with the thumb facing upward
Pain with the ‘empty can’ that resolves with full can indicates a rotator cuff tear
How would you perform a modified Hawkins/Kennedy test?
Flex shoulder to 90 and flex elbow to 90 in transverse plane
Apply an internal rotation force
Pain indicates impingement
How would you perform a scarf test?
Shoulder flexed to 90, elbow flexed to 90 and horizontally adduct
If symptoms are reproduced over the AC joint this indicates AC joint pathology such as arthritis or ligamentous tear which can also be indicative of shoulder impingement
Why does posterior capsule tightness cause shoulder impingement?
Tight posterior capsule can push the humeral head forward and upward to narrow the subacromial space
What are the four stages of adhesive capsulitis?
- Pain
- Pain and stiffness
- Stiffness and pain
- Recovery
What might you expect from a subjective assessment of someone who has adhesive capsulitis?
Between 45 and 70 (although any age is possible)
Gradual onset
Pain on reaching up, reaching behind to put a bra on, get something out of a back pocket etc
Stage 1 and 2 - diffuse and disabling pain that worsens at night
Stage 3 - Pain is decreasing but range of movement is limited, scapulohumeral rhythm is reversed
Stage 4 - Pain continues to decrease and range of movement increases again
What would you expect from an objective assessment of someone with adhesive capsulitis
Pain and limited passive lateral rotation and abduction (flexion is less impacted)
Negative impingement tests but reduced lateral rotation
Give the treatment for adhesive capsulitis at its various stages
Stage 1 and 2 - Pain management - infection, mobilisation, NSAIDs/analgesics, TENs and active movement
Stage 3 - Limited things you can do, mobilisations can increase soreness over time even if providing short term increase in range of movement
Stage 4 - Limited treatment required, hand behind back is one of the last movements to return so you can give range of movement exercises for that
What tests should you do if you suspect impingement
Painful arc test
Empty can test
Hawkins-Kennedy test
What tests should you do if you suspect pathology of the AC joint?
O-briens test
Cross body adduction test
What tests should you do if you suspect rotator cuff tears?
Lag signs:
External rotation
Internal rotation
What tests should you do if you suspect instability?
Sulcus (inferior)
Apprehension/relocation (anterior)
Jerk (posterior)
What test should you do to test for bicipital involvement in impingement and describe it
Speed test
30 degrees flexion, palm facing upward and examiner pushes down with patient resisting this
If pain experienced, positive for pain in the bicipital groove
What test can you do to look for posterior capsule tightness
Patient in supine, hold their scapula (and orient it so the medial border is vertical if not already) and then flex shoulder and elbow to 90 and cross adduct, scapula movement shouldn’t occur until around in line with the shoulder, if it does, posterior capsule tightness is indicated
Describe how you would assess for and treat thoracic spine involvement in shoulder pain
Aid patient to do thoracic side flexion and then see if their symptoms improve during flexion, if so thoracic spine may be involved
If thoracic spine is indicated, you can do transverse and PA glides
Describe what the results of the external rotation and internal rotation lag signs indicate
External rotation tests posterosuperior cuff as per the following
Internal rotation tests anterior cuff as per the following
Progressive improvement = firing problem not weakness
Shakes/wobbles and resumes position = weakness
Lags/drops = full thickness tear
How do you perform the o’brien’s test
90 degree shoulder flexion, 10-15 degrees horizontal adduction, internally rotate shoulder and pronate forearm, patient applies upward force
Repeat without the internal rotation and pronation
Positive for AC joint pathology if superficial pain occurs in the first test which is reduced or absent in the second test
How would you test inner range traps and why
Test inner range traps as this is the weakest area of the muscle
Have the patient in prone with their arm horizontally above their head, get them to lift it and resist the practitioner pushing them down
How would you test anterior cuff strength
90 degrees shoulder flexion and 90 degrees elbow flexion and then apply a force downward for the patient to resist
Weakness in anterior cuff if this is difficult
How could you give a simple treatment technique to a patient with pain reaching forward due to ac pathology
Have them reach in the scapula plane, push the clavicle AP and have them stretch their arm out
