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CHI309 - Chiropractic skills and Principles 2 > Lecture 3 - Shoulder > Flashcards

Lecture 3 - Shoulder Flashcards

1
Q

Articulations of the shoulder?

A 
Sternoclavicular 
Acromioclavicular 
Scapulothoracic 
Glenohumeral 
note: all these structures move as a unit
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2
Q

What is the purpose of the labrum?

A

A fibrous structure that acts as a anchor point for the capsuloligamentous structures and long head of the biceps as well as contributing to the stability of the joint

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3
Q

The anterior portion of the capsule is reinforced by 3 ligaments what are they?

A

Superior Glenohumeral ligament
Middle Glenohumeral ligament
Inferior Glenohumeral ligament

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4
Q

As well as the 3 Glenohumeral ligaments, what muscles contribute to joint stability?

A

Subscapularis
Supraspinous
Infraspinatus
Teres minor

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5
Q

What structures allow suprahumeral gliding?

A

Coracoacromial arch

Proximal part of the humeral head which is covered by the cuff Long head of the biceps

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6
Q

The Acromioclavicular joint stability

A
  • the A-P stability is controlled by the AC ligament

- the vertical stability (S-I/I-S) is controlled by the coracoclavicular ligament

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7
Q

The sternoclavicular joint is reinforced by what?

A
  • anterior and posterior sternoclavicular ligaments

* interclavicular ligament

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8
Q

What are the three extracapsular ligaments?

A
  • Coracoacromial ligament
  • Trapezoid ligament
  • Conoid ligament
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9
Q

What muscles form the scapula stabilisers?

A
  • Serratus anterior

- Rhomboid minor and major

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10
Q

What are the four rotator cuff muscles? SITS

A
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
    NOTE: deltoid also has a role to play
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11
Q

The rotator cuff muscles form what kind of stabilises to the GH joints?

A

Dynamic stabilisers

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12
Q

Name the three major postural muscles?

A
  • trapezius
  • pectoralis minor
  • levator scapula
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13
Q

What muscles contribute to GH abduction?

A
  • Deltoids
  • Supraspinatus
  • Upper trapezius
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14
Q

What muscles contribute to GH adduction?

A
  • Teres minor and major
  • Pectoralis major
  • Latissimus Dorsi
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15
Q

What muscles contribute to GH joint medial rotation?

A
  • Teres major
  • Pectoralis major
  • Latissimus dorsi
  • Subscapularis
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16
Q

What muscles contribute to GH joint lateral rotation?

A
  • Infraspinatus

- Teres minor

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17
Q

What muscles contribute to GH flexion?

A
  • Pectoralis major
  • biceps brachii
  • Subscapularis
  • deltoid
  • coracobrachialis
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18
Q

The Rotator Cuff muscles purpose?

A
  • they all arise from the scapula and attach to the humeral tuberosity
  • they rotate the humerus in respect to the scapula
  • they compress the humeral head into the glenoid fossa
  • provide muscle balance
  • they provide an important role in capsular stability
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19
Q

When you are observing the shoulder, what should you be looking for?

A
  • bulk, symmetry, sulcus sign
  • ROM in all movements
  • apleys “ scratch” test as a screen
  • active abduction ( painful arc?)
  • active abduction ( watch posteriorly for scapula humeral rhythm)
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20
Q

Evaluation of the shoulder: scapulohumeral rhythm

A
  • should be a smooth coordinated movement
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21
Q

Evaluation of the shoulder: 0-30 degrees abduction

A
  • deltoid and rotator cuff

- scapula remains stabilised, GH moves only

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22
Q

Evaluation of shoulder: 30-180 degrees abduction

A
  • 1:1:5 ratio of scapula: GH movement
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23
Q

Altered scapulohumeral rhythm can be due to?

A
  • excessive scapula movement due to decreased rotator cuff strength- patient has to move the scapula so allow for abduction of the arm
  • excessive upper trapezius activation causes a hitch in the scapula, usually due to deltoid weakness
  • weak Serratus anterior/ rhomboid muscle causing “winging” of the scapula
  • hypertonic pec minor muscles causing a forward tilting of the scapula
    Note: all of these indicate shoulder injury, especially rotator cuff injury
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24
Q

Musculoskeletal sources of shoulder pain

A
  1. Myofascial
  2. Rotator cuff injury
  3. GH instability
  4. Glenoid labrum tear
  5. Bursitis
  6. Impingement syndrome
  7. AC joint injury
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25
Q

Supraspinatus as a cause of pain

A
  • a cause of both shoulder and elbow pain

- mimics lateral epicondylitis (tennis elbow)

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26
Q

Infraspinatus as a cause of pain

A
  • follows the same pattern of radicular pain down the arm
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27
Q

Teres minor as the cause of pain

A

Pain referral often know as the silver dollar sign, which is an area the size of a U.S. Dollar on the lower posterior deltoid

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28
Q

Subscapularis as a cause of pain

A
  • pain refers to the posterior aspect of the GH joint, down the posterior arm and to the WRIST
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29
Q

The Fibrocartilaginous disc of the sternoclavicular joint is attached to bony structures how?

A

Superiorly to the clavicle

Inferiorly to the manubrium

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30
Q

The disc orientation of the sternoclavicular joint helps to do what?

A
  • resists the clavicle from being pushed medially over the manubrium
  • allows shock absorption from the arm to the manubrium
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31
Q

Most sternoclavicular injuries occur due to a direct blow from what?

A

2/3 car accidents

1/3 sports related

32
Q

Why are posterior dislocations more clinically important than anterior dislocations

A

Because more damage would have occurred if it moves posteriorly, more muscle and bone involvement

33
Q

What structures form the static stabilisers of the AC joint?

A
  • coracoclavicular ligament

- Acromioclavicular ligament

34
Q

What structures form the dynamic stabilisers of the AC joint?

A
  • upper trapezius

- deltoid

35
Q

Rock wood classification of AV ligamentous injuries and dislocations

A

Look on slide

36
Q

Signs and symptoms of AC injury

A
  • pain reported at superior shoulder over AC
  • history if MOI?
  • history of exacerbation sleeping on that side
  • asymmetry may be evident
  • pain at end range of abduction (painful arc more than 120 degrees) as well as horizontal abduction
  • tender to palpate over AC joint
  • AC specific orthopaedic tests provoke pain
37
Q

Describe osteoarthritis of the AC joint

A
  • results from repetitive minor stress, previous injury of clavicle fracture
  • can contribute to degenerative Supraspinatus tear and impingement syndrome
38
Q

Describe adhesive capsulitis or frozen shoulder

A
  • characterised by stiffness and pain in the shoulder, usually unilateral but occasionally can be bilateral
  • capsular pattern is typical: loss of external rotation, abduction and internal rotation (active and passive)
  • very uncommon in patients below the age of 40, more common above the age of 50
39
Q

Adhesive capsulitis: causes

A

Strong predilection for women in early menopausal and early post menopausal age, diabetic and hypothyroidism
Can be either Primary: (uncommon)
—No cause can be established (aetiology unknown / idiopathic) or
Secondary: (more common)
—Can be attributed to other illnesses or occur secondarily to other injuries
— Such as?

40
Q

Phase 1 of adhesive capsulitis

A

NATURAL HISTORY: Typically occurs in 3 stages:
Phase I (FREEZING STAGE)
• Pain is the primary symptom
• Progressive loss of ROM and function due to pain
inhibition (thus freezing)
• Last approximately 3-6months
Treatment at this stage usually includes:
1.Active range of motion exercises

  1. Gentle joint mobilization
  2. NSAIDs
  3. Possibly intra-articular corticosteroid injection (usually if non-responsive to the above conservative care)
41
Q

Phase 2: adhesive capsulitis

A 
Phase II (FROZEN STAGE)
• Pain lessens and stiffness becomes the primary symptom (thus frozen)
• Lasts 4-12 months (longest stage) 
Treatment at this stage includes:
1.Mobilization to restore joint play
2.Heat, ultrasound, TENS, and dry needling
3.Must attempt to increase the range of motion with care in not increasing the pain
42
Q

Phase 3: adhesive capsulitis

A 
Phase III (THAWING STAGE)
• Gradual return of ROM 
• Lasts 12 months - years
43
Q

Studies on adhesive capsulitis - read over

A

The average duration is reported to be 30.1 months (4 – 42 months).*
A longer frozen phase is usually associated to a longer thawing phase.
Hand et al. (2008) reported that 41% of people suffering from FS had ongoing symptoms on average 4.4 years later (4 – 20 years)
There is no Gold Standard test to diagnose FS
Diagnosis rely solely on the:
• Clinical evaluation
• Exclusion of other pathologies
• Normal glenohumeral radiographs

44
Q

Treatment principles of the shoulder

A

If tendonitis / strain / mild tear
• Conservative treatment methods: STT, stretch, M&M
• If moderate to full tear
• Co-manageifmoderate,or refer for either!
• Determine if instability is present
• Follow basic rehabilitation principles(next)
• Refer or co-manage if indicated

45
Q

Increase flexibility of shoulder capsule and musculature

A

Following periods of inactivity / inflammation (x4)
• Stretching of anterior capsule and pecs
• Stretching of posterior capsule
• Apley’s “scratch” positions (Can be modified using a towel for a start)
- Codman’s pendulum exercises

46
Q

Increase strength of rotator cuff musculature

A

Especially indicated for instability
— Begin with RIM in ER and IR with arm at side
— Progress to dynamic strengthening in ER and IR with arm still at side (Theraband)
— Eventually strengthen in FF with Theraband, adding
— ABD to 90 only with Theraband (if no contra-indications)

47
Q

ADVICE for SHOULDER CONDITIONS

A
  • ACTIVITY MODIFICATION

* ADL’S

48
Q

Rotator cuff injury

A

Rotator cuff injury most often involves
SUPRASPINATUS
• Tendinopathy – often causing impingement
Rotator cuff injury (tears) are either:
• Traumatic
• Degenerative

49
Q

Yamamoto et al 2010, Prevalence and risk factors of rotator cuff tear in the general population

A

• Prevalence: 20.7%, ↑with age
• In the 683 people that were examined,
• 36% of subjects with current symptoms had RCT; • 16,9% of subjects without symptoms had RCT
• RCT are most commonly associated with:
• Males, elderly patients, dominant arm, heavy labour, history of trauma, patient with a +ve impingement sign, lesser active forward elevation, weaker strength in abduction and external rotation.
• Risk factors:
• History of trauma,
• Paininthedominantarmand • Age

50
Q

Supraspinatus function

A

Functions in both abduction (+++) and flexion (+) like the deltoid
Activity is fairly constant through ROM and larger than the deltoid for the first 600of abduction
Secondary functions:
1. compression of the GH joint
2. acts as a vertical “steerer” for the humeral head and
3. maintains stability of the arm

51
Q

Rotator cuff tear prevelance

A

Typical patient with a RCT is in late middle age and has had problems with the shoulder for some time
• This patient then lifts a load or suffers an injury that tears the tendon
• RCT also occurs in young people
• Overuse or injury at any age can cause rotator cuff tears
Because the RC tendons have areas of very low blood supply, it makes the tendons vulnerable to degeneration from aging. This deficient blood supply helps explain why the RCT is such a common injury later in life.

52
Q

Rotator cuff tears

A
  • Excessive force can tear weak rotator cuff tendons
    • Force can come from:
    • Trying to catch a heavy falling object
    • Lifting heavy object with the arm abducted
  • Fall directly onto the shoulder
    • Sometimes RCT injuries are painful, but sometimes they aren’t – WHY?
    • 40% of people may have a mild RCT without even knowing it
53
Q

Rotator cuff injury test- empty can

A

• Tests for Supraspinatus injury
• Arm abducted 900 and flexed to 450 (scapular plane), internally rotated (hence “empty” can)
• Patient resists downward pressure by examiner
• Pain and some weakness suggests tendonitis or mild tear
• Less pain but significant weakness suggests full tear

54
Q

Biceps Tendinopathy

A

Characteristics of the condition are as follows:
• Pain is reported in the region of the anterior shoulder located over the bicipital groove, occasionally radiating down to the elbow.
• Thepainisaggravatedbyactivitiesthatrequireshoulder flexion, forearm supination, and/or elbow flexion.
• Painisusuallyexacerbatedbytheinitiationofactivity.
• Some patients describe fatigue with shoulder movements.
• Thesymptomsarealleviatedbyrest,ice,massage, stretching, and sometimes heat.
• Night pain is not uncommon.

55
Q

Long Head Biceps Tear

A

Experienced most commonly by individuals aged 40-60 years with a history of shoulder problems, secondary to chronic wear of the tendon (overuse).
Younger individuals may rupture the biceps tendon following a traumatic fall, during heavy weightlifting, or during sporting activities (eg, snowboarding, football).

56
Q

Signs and symptoms of long head bicep tear

A

• Ecchymosis and swelling appear
• Classic bunching of the tendon appears but often several days later

57
Q

Dislocation of Biceps Tendon

A

• tear to the transverse humeral ligament allows the bicipital tendon to dislocate out of the bicipital groove
• Dislocation also more frequently associated with a shallow bicipital groove

58
Q

Signs and symptoms of bicep tendon dislocation

A

• Anterior shoulder pain with popping, cracking and occasionally locking
• Shoulder pain is present when the arm is abducted 900 and rotated internally and externally

59
Q

Bicipital tendonitis test- speeds test

A

• Tests for Biceps injury
• Arm forward flexed, externally rotated (palm up)
• Patient resists downward pressure by examiner
• Pain and some weakness suggests tendonitis or mild tear
• Less pain but significant weakness suggests full tear

60
Q

Shoulder stability relies on what structures?

A

Stability relies on:
1. Joint – glenoid labrum deepening the GH “socket”
2. Ligaments and joint capsule
3. Muscular stabilization
Instability usually occurs when an injury affects 2 or more of the above

61
Q

Stability of the GH Joint

A

Static stabilizers
• Joint shape including labrum (creates a –ve intra-articular
pressure (a “suction”))
• Capsule & GH ligaments
Dynamic stabilizers
• Rotator cuff musculature (SITS)
• LH of biceps
• Scapular stabilizers • Rhomboids
• SerratusAnterior
• Deltoid (specifically adds to –ve intracapsular pressure!)

62
Q

Glenohumeral Instability

A

Classified in terms of direction of instability and whether the incidence is traumatic or non-traumatic
• Anterior (traumatic most common in young active patients)
• Posterior
• Multidirectional
Non-traumatic instability is often associated with connective tissue disorders or generalized laxity.

63
Q

Glenohumeral instability - anterior apprehension test

A

• Patient supine, arm abducted to 900 and externally rotated
• Pain and/or apprehension to the movement suggests anterior instability

64
Q

Recurrent Post-Traumatic Instability

A

• Most common in males

65
Q

Glenoid Labrum: SLAP Lesions (superior Labrum Anterior Posterior)

A

—Classified into types I-IV depending on tear position and integrity of biceps tendon

66
Q

SLAP lesion- ACTIVE COMPRESSION TEST OF O’BRIEN

A

—Patients arm is fully internally rotated forward flexed (step 1).
—Patient resists downward pressure on the arm
—Patient then fully externally rotates arm and resists downward pressure again (step 2)
—+ve for SLAP lesion if internal shoulder pain in step 1 but not in step 2

67
Q

Glenohumeral dislocation

A

• Traumatic, anterior
• May be associated with neurovascular compromise
• High rate of recurrence
• Often requires surgery and significant rehabilitation
2 major types

68
Q

Glenohumeral dislocation- 2 major types

A

2 major types of classification
TUBS
— Traumatic
— Unidirectional
— Bankart labral lesion present — Surgery often required
AMBRI
— Atraumatic
— Multidirectional
— Bilateral (often)
— Rehabilitation best course of care
— If surgery is needed inferior capsular shift is performed

69
Q

Anatomy of the Coracoacromial Arch

A

• Formed by the:
• Acromion process
• Coracoacromial ligament
• Inferior surface of the AC joint
• Greater tuberosity and Humeral Head
• These anatomical structures forms a subacromial space / outlet through which these pass:
• Supraspinatus
• Subacromial (subdeltoid) bursa

70
Q

Diagnosis associated with rotator cuff impingement

A
  • Subacromial bone spurs and/or bursal hypertrophy
  • Acromioclavicular joint arthrosis and/or bone spurs
  • Rotatorcuffdisease
    • Superior labral injury
    • Glenohumeral internal rotation deficit • Glenohumeral instability
    • Bicepstendinopathy
    • Scapular dyskinesis
    • Cervicalradiculopathy
71
Q

Acromion Type

A

• Type I: Straight
• Type II: Curved
• Type III: Hooked (strongly associated with rotator cuff tear)

72
Q

Impingement

A

• Most common cause of shoulder pain
• Pain usually is reported over the lateral, superiorshoulder
• Typical pattern is a “painful arc”
•Often pain during sleep, in various sleeping positions, with activity, esp overhead activities, often pain at rest due to inflammation
• In older patients, additional OA of the AC joint contributes to impingement

73
Q

Shoulder impingement may be either two things, what are these?

A
  1. External
    • Primary (abnormalities of the superior structures)
    • Secondary (excessive angulation of the acromion due to inadequate muscular stabilization of the scapula)
  2. Internal (glenoid) (overhead sport in late cocking stage of throwing)
74
Q

IMPINGEMENT SYNDROME- neer test

A

• Patients arm is fully internally rotated and abducted maximally by examiner (passively)
• Patient experiences pain in the shoulder around the AC joint if impingement is present

75
Q

subacromial/subdeltoid bursa

A

Lies between the RC tendons and the undersurface of the acromion, the acromioclavicular joint and the deltoid muscle, underlying the bicipital groove.There is normally no communication between the bursa and the joint; only occur with full RC tears.

76
Q

Pathological conditions that may cause SASD bursitis?

A
  1. Acromioclavicular joint disorders
  2. Supraspinatus tendon tear
  3. Acute shoulder trauma
  4. RA
  5. Infection (rare)
  6. Pigmented villonodular synovitis
77
Q

Subacromial bursitis causing pain and impingement

A

• Due to limited subacromial space, inflammation of the subacromial (subdeltoid) bursa causes pain and impingement
• Distinction can be made as bursitis often presents with localized warmth and erythema due to inflammation of the relatively superficial bursa
• Responds well to NSAID’s, ICE and rest

CHI309 - Chiropractic skills and Principles 2 (7 decks)

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