MSK week 2 module 2 shoulder Flashcards
the GH joint has _ degrees of freedom
6
scapulae provides a stable/mobile _____ on thorax
base
SC joint provides ….
AC joint provides …
SC joint provides central attachment
and stability
o Minimal movement
AC joint provides stability for GH joint
o The “ceiling” for the subacromial space
neurovascular characteristics of shoulder
the three triangles
anterior triangle
posterior triangle
and another ?
Sensorimotor (nerve contribution and location sites in the area)
Entire arm supported from C5-T1
Different trunks and branches to different muscles
brachial plexus
Roots > trunks > divisions > cords
-c5
-c6
-c7
-c8
-T1
Roots > _____ > division > ________
roots trunks division cords
spinal accessory nerve cranial nerve XI and c3-4
Motor
impact
motor SCM and traps
impact of lesion
inability to abduct the arm beyond 90 degrees
pain in the shoulder with abduction
musculocutaneous nerve c5 -7
motor
impact
motor
coraco, biceps brachii, brachialis
impact of lesion
weak elbow flexion with forearm supinated
long thoracic nerve c5-7
motor
serratus
impact of lesion
pain on flexing a fully extended arm
inability to fully flex an extended arm
winging of the scap at 90 degrees of forward shoulder flexion
suprascap nerve c5-6
motor
impact
motor
supra and infra
impact of lesion
increased pain on forward shoulder flexion
pain increased with scap abductino
pain increased with c/s rotation to the opposite side
axillary nerve c5-56
motor
impact
motor delts and teres minor
impact of lesion
inability to abduct the arm with neutral rotation
thoracodorsal nerve c6-8
motor
lats
impact of lesion
marked difficulty to resist shoulder extension
marked difficulty to resist shoulder IR
c/s nerve root test
motor
multiple peripheral nerves
impact of lesion
varies according to the level involved, so it can include various combos of the other nerve lesions
Capsuloligamentous structures
INERT tissue
Labrum deepens glenoid cavity
Ligamentous/capsular redundancy to allow for mobility and stability
static restraints to degrees of G-H abduction
@ 0
@ 90
degrees of G-H abduction
@ 0 superior GH and coracohumeral ligaments
@ 90 inferior GH ligament (posterior band in ER, the anterior band in IR)
static restraints to degrees of GH IR
@ 0 posterior band of inferior GH ligament, teres minor, posterior capsule (superior)
@ 45 anterior and posterior bands of the inferior G-H ligament
@ 90 posterior band of the inferior GH ligament, posterior capsule (inferior)
dynamic and static restraints to GH ER (dependent on the position of the am)
@ 0 supscaularis, superior G-H, and coracohmeral ligaments
@ 45 subscapularis, middle G-H ligament, superior fibers of the inferior G-H ligament
@ 90 inferior G-H ligament
Clinical Examination – Patient History
- Items for review
- Patient intake form
- Body Chart
- Medical referral
- Outcome measures
- Quick Disability of Shoulder and Hand Form (Quick DASH)
- Fear Avoidance Beliefs Questionnaire (FAB-Q)
Clinical Examination - Observation
- 30 Second Snapshot
- Age
- Ethnicity
- Gender
- Morphology
- Past Medical History (PMH)
- Key items to consider
- Muscle tone
- Ecchymosis, swelling, bruising
- Joint position
- Posture! Secondary impairments
Patient History
- Mechanism of Injury (MOI)
- Insidious injuries
- Subacromial space
- Labral fraying
- Degenerative changes
- Traumatic Injuries
- Direct trauma - Humeral neck common fracture site
- FOOSH injury - Fracture, plexus injury, blunt trauma
- Peel off/traction injury – labrum, RTC
- Occupation/ADLs
- Humeral neck common fracture site
Patient History - Location
- Anatomy
- Tissue structure
- Radiating – past the elbow?
- Alleviating
Patient History – Location Referral
- Deltoid from RTC
- Differentiating subacromial pain
- Nerve pathways
Patient History - Behavior of symptoms
- Pain
- Instability
- Stiffness
- Deformity
- Locking
- Swelling
- Other – catching, clunking, grinding, or popping
- Time of day
- Early morning = OA
- Repetitive use OH = impingement
- Heavy/cold = TOS
Behavior - Motion Restriction
- Overhead motions = provocative
- Limitations to assess:
- Flexibility
- Mobility
- Strength
- GH rotation = loss to achieve full elevation
- Scapular mobility = loss to clear subacromial space
Behavior - Stage of Healing
acute / inflammatory : red/warm/swollen etc
sub acute : symptoms usually occur with activity or motion of the involved area
Chronic or remodeling: the symptoms usually occur after the activity
Behavior of symptoms - Nature
- *Goal: ID tissues involved in this
pathology - Aggravating factors
- Easing factors
- Quality of pain
Behavior - Boney pathologies
- Falls -> humerus fractures
- FOOSH -> AC joint
separations or fracture,
brachial plexus injury
Behavior - Muscle Strains
- Strain – Grade I, II, III Tear
- Chronic in nature, or an acute exacerbation
- Muscle tone changes
Behavior - Tendon Pathologies
- Traumatic MOI often needed for complete tear of tendon
- RTC tearing can occur for 1 or all 4 muscles
- Surrounding musculature also
- Insidious MOI is often due to mechanical compression or repetitive tension over time
- Biceps tendonitis common as a secondary complaint
Shoulder Pathologies
- Prevalence:
- 16% worldwide
- 3
rd most common behind
low back and knee - Incidence:
- 37.8 per 1000 persons/year
- Age/index of suspicion
- Adhesive Capsulitis
- RTC degeneration
- Chondrosarcomas
- Calcific Deposits
- Apophysitis
Systems Review - Scanning
- Looking for mechanical explanation
- RTC tear
- Adhesive capsulitis
- AC joint sprain
- Bursitis/tendonitis
- Primary Care hat to confirm no systemic involvement
- Cervical myelopathy
- Systemic infection
- MI
- Stroke
level of concern
low no concerning features - begin PT / home management
mod concerns yellow - being PT watchful waiting
mod concerns orange - urgent referral no PT develop a plan
high concerns - ER referral, command the next move
