lecture 9- shoulder Flashcards
Deep stabilizers (or rotator cuff: SSIT on humeral head)
-Supraspinatus; initiates abduction
-Subscapularis; internal rotation
-Infraspinatus; external rotation
-Teres minor; external rotation, adduction
Bursae shoulder
Subdeltoid and subacromial
shoulder injury mechanisms
Throwing, direct blow, resisting a force (especially in abd/ER), fall on outstretched arm (FOOSH)
Frozen shoulder=
capsule tightens up, gradually ‘thaws’ on its own, don’t know why, no real treatment, common in older females
Shoulder Contusion
Hx: direct blow
SSx: pain, tenderness, reduced ROM, bruising, swelling
Tx: POLICE, early ROM, no massage, or heat!!!!
shoulder Strain
Injury to muscles or tendon
Hx: resisting a force, pain worse when using muscles
SSx: pain, worse with active movement, reduced ROM, point tenderness (bruising)
Tx: POLICE, early ROM, NSAIDs, tape, physio and rehab
–> 3rd degree strains may need surgery
Tendonitis (Tendinopathy)
Hx: acute strain, overuse, impingement (ex. swimming)
SSx: acute strain but prolonged duration (imaging xray/diagnostic ultrasound)
Tx: NSAID /corticosteroid injection (not recommended anymore!!!), ROM, rest, physio, rehab, surgery?
Impingement= pinched nerves
(intrinsic and extrinsic)
- Intrinsic (primary) impingement
= something within the subacromial space is decreasing the space that is there.
Risk factor: if subacromial space is less than 7mm (bony formation - Extrinsic (dynamic instability)
= something is functionally wrong with the shoulder that is allowing it to go in positions that may cause impingement
treatment= getting people to “set their shoulders/retract scapulae”, to prevent tissues from getting caught on each other during shoulder flexion for example
Bursitits
Hx: acute trauma or overuse
SSx: aching pain, tenderness, reduced ROM (abd), may lead to frozen shoulder
Tx: same as tendinopathy
Sternoclavicular sprain (SC)
Hx: direct blow, torsion, fall
1st deg:
SSx= pain, tenderness, no deformity
Tx= rest, ice, NSAID, rehab
2nd deg:
SSx=as above plus deformity, crepitus, bruising, reduced shoulder ROM
Tx= sling (4-6 weeks), ROM, NSAID, physio, rehab
3rd deg:
SSx= as above plus marked deformity
Tx= as above but first sling, stabilize, hospital
Tends to recur easily
**2nd and 3rd degree send to hospital for imaging!!!! If clavicle is displaced posteriorly, it may out pressure on blood vessels, esophagus or trachea!!!
Acromioclavicular sprain (AC)
Hx: direct blow, fall
1st deg:
SSx= pain, worse on movement, point tenderness, swelling, mild deformity
Tx= POLICE, sling, ROM, physio
2nd deg (rupture of AC ligament):
SSx= as above plus more deformity, crepitus?, marked restriction in ROM
Tx= ice, sling, to hospital for xray, NSAID, physio, rehab
3rd deg (rupture of AC and CC):
SSx= marked deformity (step defect), pain etc.
Tx= as above, surgery?
Glenohumeral sprain (GH)
Hx: resisting a force (Abd, ER), fall, throwing
SSx= same as rotator cuff strain but pain is marked both on active AND passive movement
Tx= POLICE, sling, early ROM, NSAID, physio
**Note: 3rd deg GH sprain= glenohumeral dislocation
Glenohumeral dislocation
Hx: same as GH sprain
–> Forward (anterior, subcoracoid) (much more common)
SSx= humeral head palpable in axilla, deltoid flat, indented, arm in abduction, severe pain, reduced ROM
Tx= check neurovascular status! NPO, sling, to hospital (xray), reduction, surgery if recurrent!
Brace limits the movement
–> Downward (posterior, subglenoid)
SSx= same, except arm seems longer
Tx= same
recurrence is common!!!
Glenohumeral dislocation management
- Immediate immobilization, sling
- Reduction by physician
- Xray to make sure no fractures
- General body conditioning
- ROM
- Muscular strength
- Neuromuscular control
- Functional progressions
- Return to activity
SLAP tears (Labrum tear)
= Superior Labral tear Anterior to Posterior
Type 1:
- Partial tear of labrum where edges are roughened but not completely detached
- Tx is normally to clean the edges
Type 2:
- Most common
- Labrum is torn off the bone due to glenohumeral dislocation
- Tx is reattachment if the labrum (arthroscopically)
Type 3:
- “bucket handle” tear of labrum, torn piece hangs into GH joint and causes locking, popping and clunking
- Tx: removal or bucket handle segment
Type 4:
- Tear of labrum extends into long head of biceps tendon
- Tx is reattachment of labrum and repair of biceps tendon
Fraying of fibres
Surgery goes in to clean up edges
Glenohumeral fractures
Hx: dislocation
SSx= same as dislocation
Types=
–> head of humerus (Hill-sachs or Hatchet)= anterior dislocation
–> glenoid process (Blankhart lesion)= fracture TO the glenoid cavity
Tx= hospital to assess, Xray, surgery
Complications= neovascular, arthritic
Clavicular fracture
Hx: direct blow, fall (mid 1/3)
SSx=deformity, crepitus, pain, tenderness, swelling, marked reduction in ROM, positive Xray
Tx= check neovascular status, hospital to assess, sling (6-8 weeks), physio, surgery is rare!!!
dynamic instability
decreased subacromial space during shoulder elevation
upwards translation of humeral head
primary impingement surgery
surgery to increase subacromial space
tendon repair
calcification
osteophytes/bone spurs
subacromial depression
risk factor for primary impingement?
subacromial space less than 7mm
external rotation? working with hands above head?
what is important for pitchers?
to have coordinated superior and deep stabilizers of the shoulder
internal rotators need to overcome a huge amount of resistance
–> if not, impingement!!!
shoulder rotation deg/s
6950
shoulder assessment?
Hx and PHx
tenderness, pain
deformity>
ROM
special tests
palpation
neovascular status (brachial plexus, subclavian artery, brachial artery)
beware of rapid onset of “frozen shoulder” if immobilized due to pain
Mechanisms of shoulder injuries
throwing
direct blow
resisting a force (esp abd and IR)
FOOSH (fall on outstretched arm)
Arch of the shoulder
coracoacromial arch
dynamic stabilizers; force couples
forces act in opposite direction and create rotation at scapula
Dynamic stabilizers of the shoulder (“deep”)
“Deep” group muscles/rotator cuff muscles
SSIT
supraspinatus (abd, stabilize head)
subscapularis (ER)
infraspinatus (ER)
teres minor (add, ER)
Dynamic stabilizers of the shoulder (“superficial”)
deltoid (abd)
pec major (add, flex, IR)
latissimus dorsi (add, abd, IR)
teres major (add, ext, IR)
3 passive stabilizers
bony anatomy (head of humerus in glenoid cavity)
capsular and coracohumeral ligaments
labrum
3 dynamic stabilizers (general)
superficial muscles
tendon of long head of biceps humerus
rotator cuff muscles
shoulder does (movement)
circumduction
AC joint
synovial, gliding
scapula (acromion process) and clavicle pivot on eachother
–> elevation, depression, retraction
Coracoclavicular joint
syndesmosis
helps w AC joint stability
sternoclavicular joint
synovial
mainly rotation, plus elevation of retraction
glenohumeral joint
ball and socket, synovial
