Shoulder Flashcards
1
Q
What are the muscles of the rotator cuff?
A
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
2
Q
What is the function of Supraspintus?
A
Abducts the arm
3
Q
What are the attachments of Supraspinatus?
A
O: Supraspinous fossa
I: Superior and Middle of the facet of he greater tuberosity.
4
Q
What is the action of Infrapsinatus?
A
Externally rotates the arm
5
Q
What are the attachments of Infraspinatus?
A
O: Infraspinatous fossa
I: Posterior facet of the greater tuberosity
6
Q
What is the action of Teres Minor?
A
Extenally rotates arm
7
Q
What are the attachments of Teres Minor?
A
O: Middle half of the lateral border of the scapula
I: Inferior facet of the greater tuberosity.
8
Q
What is the first rule postoperatively?
A
Always follow surgeon’s protocol
If not provided- call and ask
If you want to vary, always ask
9
Q
What are the types of shoulder surgery
A
Acromioplasty/subacromial decompression
Rotator cuff repair
Shoulder stabilisation
Total shoulder replacement
Reverse totally shoulder replacement
10
Q
How can subacromial decompression surgery be done?
A
Arthroscopic (usual) or open
11
Q
What is subacromial decompression done for?
A
To increase space under subacromial arch
12
Q
Indications for subacromial decompression surgery?
A
Relieve pain from impingement where Conservative measures (physio, corticosteroid injections) have failed
13
Q
What injuries can occur at the acapulothoracic joint?
A
Fractures (MVA,MBA,fall,direct blow)
Snapping scapula
14
Q
What is snapping scapula characterised by?
A
Loud pop/snap or crepitus when scapula cannot move smoothly over rib cage during arm elevation
Infra-serratus bursae can become enlarged, inflamed and fibrotic
15
Q
Causes of snapping scapula
A
Scapular dyskinesia Muscle strength/length deficits Poor scapulohumeral rhythm Infra serratus bursitis Osteochondroma (benign tumour) Rib/scapular fractures Neural paralysis
16
Q
How can snapping scapula be treated?
A
Physiotherapy
Injection of bursae
Surgery
17
Q
What is scapula dyskinesis
A
Alteration in normal position or motion of the scapula during coupled scapulohumeral movements
18
Q
What is physiotherapy for snapping scapula?
A
Check/address lengths of muscles attaching to scapula
Improve muscle strength traps and SA
Correct resting position scapula on thorax
Retrain motor control of scapular movement through range of elevation
19
Q
Surgery for snapping scapula
A
Debridement of bursae
20
Q
How common are sterno-clavicular joint sprain/dislocation and in which direction?
A
Rare 3% of all fractures and dislocations around shoulder
Majority- anterior
Posterior - potentially life threatening
21
Q
What is serious complication of sterno-clavicular joint sprain?
A
May cause pressure on trachea, oesophagus and/or major vessels
22
Q
What are mechanisms of injury SC joint?
A
Direct- blow to medial clavicle
Seatbelt injuries
Indirect-
Athlete lying on side - uppermost shoulder compressed and rolled backward
23
Q
Signs and symptoms SC joint dislocation
A
Derformity, local pain and tenderness (arm rolled forward)
SOB, venous congestion in neck (posterior) dislocation
24
Q
What are the degrees of SC dislocation?
A
First degree
Second degree
Third degree
25
What is a first degree SC dislocation?
Minor tearing SC and CC lig- no true displacement
26
What is a second degree SC dislocation?
Complete tear sc; second degree tear cc lig- subluxation
27
What is a third degree SC dislocation?
True dislocation 3rd degree sprain to sc/cc lig
28
What is early treatment for SC joint dislocation?
Rest/ice/NSAIDs
Gentle joint mobilisations for pain relief
Clavicle strap
29
What is later stage treatment for SC joint dislocation?
Joint mobilisations - A/Ps, MWMs (A/P,P/A/rotation with shoulder elevation)- which direction is the deformity?
Gentle muscle/massage
30
What are complications of SC joint injuries?
Instability
Cosmetic deformity
Recurrent instability
Chronic subluxation - damage to intro-articulate disc long term
Discomfort with repetitive/strong upper limb
31
What is the MOI of clavicle fracture?
Fall onto tip shoulder
| Direct contact with opponent
32
Complication fracture middle third of clavicle
Often much overlap - dysfunction
33
Treatment for middle third clavicle
Conservative - fig 8 bandage + passive/assisted active ROM to 90 degree flexion
34
Distal end clavicle fracture:
How common
Complications
Treatment
12-15%
Involve cc and AC ligaments more prone to nonunion
Conservative-sling+AAROM/isometric exc
35
Injuries at AC joint
Sprain/dislocation
Osteolysis distal end clavicle
Osteoarthritis
36
How common is AC joint sprain
Most frequently injured joint in football, ice hockey, skiing and rugby (12% dislocations)
37
S&S AC joint spraint
Local pain, step deformity, instability, restriction shoulder movement
38
MOI AC joint sprain
Fall onto point of shoulder
Direct blow to shoulder
Fall onto outstretched hand
39
What is a type 1 AC joint sprain
Sprain capsule, 1 degree sprain AC ligament
| Local tenderness, no deformity
40
Type 11 AC joint sprain
Complete tear AC ligament, partial tear cc ligament
Local tenderness, palpable step deformity
Reduced range of motion into abduction/addiction
41
Type 111 and V AC joint sprain
Complete tear of cc ligament
Marked step deformity
Type 1V- posterior displacement clavicle
Type V1 - inferior displacement
42
What are effects of AC dislocation on scap control?
Chronic type III AC dislocation - scap dyskinesis 70.6% patient
Of latter 58.3%= SICK scapula
Dyskinesis- May be loss of stable fulcrum of shoulder fielder represented by AC joint and due to superior shoulder pain caused by dislocation
43
What is a SICK scapula?
Scapula malposition
Inferior medial border prominence
Coracoid pain and malposition
Kinesis (movement) abnormalities of the scapula
44
Management AC joint sprain acute phase
Ice/taping
Rest in sling if necessary
Isometric exercises
Scapular positioning, cervical AROM
45
Management AC joint sprain (later)
Gentle AROM to limit of pain onset to regain full ROM
mobilisation AC joint - A/P, caudad, MWM
Strengthening of all muscles shoulder girdle
Gradual return to sport
46
What is osteolysis distal clavicle?
Stress fracture
Osteolysis- softening, absorption and dissolution of none or removal/loss kg calcium
Can result in 0.5 to 3 cm of bone loss and AC joint
47
What is the MOI for osteolysis of distal clavicle
Overuse eg weight lighters who use excessive weights in bench press
48
S&S osteolysis distal clavicle
Pain, stiffness, swelling distal clavicle, pain with HF
| Xray/bone scan- moth eaten appearance
49
Treatment for osteolysis distal clavicle
Rest from activities m, NSAIDs, physiothrrapy (electro, muscle reeducation, trigger point release)
50
X-ray appearance of OA
Sclerosis and osteophytes
51
How should weight lifters bench press?
Avoid locking elbows
Narrower grip on bar
Avoid bending their elbows past horizontal
52
What are GHJconditions?
```
Hyper mobility syndrome
SLAP lesion
Dislocation- Labral tear, bankart, hill-Sachs, HAGL lesions
Capsular restrictive process
Adhesive capsulitis
```
53
What does SLAP lesions mean?
Superior Labral anterior to posterior l
54
What mag cause a slap lesion. What may it occur with
Overhead throwing can tear anterosuperior section of labrum with repeated throwing
May occur with acute and chronic overuse injuries
55
What mag anterior dislocation of GHJ cause
Bankart lesion
56
MOI slap lesion
1. Abducted/ER position- long head of biceps is vertical and angled posteriorly
- produces twist at the attachment of biceps tendon and can transmit force through to labrum, causing it to rotate medially and peel off
2. Follow through phase of throw when eccentric biceps contraction involved with deceleration at release of throw
57
Treatment slap lesion
Conservative or surgical repair
| Address biomechanics of throwing
58
S&S slap lesionina
```
Intermittent symptoms, vague ache
May be clicking or catching
May occur in conjunction with other tests
Increased joint laxity
- often secondary to other injuries
-watch post MVAs
```
59
What measures generalised hyper mobility syndrome. What tissues does this effect
Beighton score
| Type 1 collagen
60
A symptomatic hyper mobility =
Joint laxity
61
What can happen in GHJ hyper mobility
Excessive translation HOH along glenoid on load and shift test
Able to subluxate/dislocate GHJ/SCJ
Increases wear/tear
62
Symptomatic hypermobility of GHJ=
Pain provocation on apprehension test:instability/apprehension/feeling weakness
63
Treatment hypermobility GHJ
Neuromuscular control
64
Cause of anterior GHJ instability
Trauma
Overuse
Incorrect technique
65
Symptoms anterior GHJ jnstability
Increased translation humeral head-May cause pain
ROM: normal to hypermobile
Apprehension/relocation test positive
PA accessory glide may have increased anterior excursion
Often tenderness posteriorly from tractioning of post structures
66
Who has posterior instability (atraumatic)
Sports population- swimmers, gymnasts, throwers, teenagers
67
Presentation posterior instability GHJ (atraumatic)
Pain- post but also ant due to stretch of structures
Crepitus/clicking/catching/subluxation/feeling instability
Full/excessive rom
Loss normal appearance of front of shoulder
Dumps out the back
68
Cause inferior/MDI
General hyperelasticity
| Repetitive overuse or trauma
69
Presentation inferior/MDI
Lax in all directions (May only be symptomatic in one)
Positive: apprehension test, translational tests including sulcus sign
Hypermobility on other side is asymyomatic
70
What will inferior translation tension?
Superior capsule and IGHL
71
Treatment GHJ instability - all directions
```
Pain relief
Heat
Cold
NSAIDs
Soft tissue massage
TP
Electro therapy
```
72
Treatment GHJ instability - anterior
Strengthening subscap, other rotator cuff muscles
73
Treatment GHJ instability - posterior
Strengthening posterior deltoid, scapular stabilisers (infraspinatus, teres minor), rotator cuff
Appropriate taping and proprioceptive control
74
MOI anterior dislocation
Forced abduction and external rotation (stop sign)
75
Comorbid anterior dislocation
Involves damage to capsular structures
| May also include Labral, bony, ligamentous and muscular damage
76
How common is anterior GHJ dislocation
90-95% all dislocations
77
Presentation anterior GHJ dislocation
Findings may include deformity
| Prominent HOH anteriorly
78
Treatment anterior GHJ dislocation
Depends on age
20 - conservative rehab
79
MOI posterior GHJ dislocation
Generally sports population
Direct blow to shoulder or fall on outstretched arm with arm position in internal rotation and addiction (fall from bike or horse)
Usually conservative management
80
What can cause GHJ capsular restrictions?
Post injury
Inflammation
Post surgery
Post immobilisation and as part of cervical spondylitis flare up
81
Pattern of GHJ capsular restriction
External rotation more painful and > abdication, internal rotation
82
TreAtment of capsular restrictions
Early pain relief
| Joint mobilisations in opposite direction to restriction
83
Cause of adhesive capsulitis
Idiopathic insidious onset
84
Who gets adhesive capsulitis
Females (40-60) > makes (3:1)
| Predisposition with diabetes and hyperthyroidism
85
Which side does adhesive capsulitis affect?
Often unilateral but may occur bilaterally concurrently or in sequence (15%)
86
Characteristics adhesive capsulitis
Progressive loss of movement and gradual increase in pain
| Loss of active and passive movement- ER> abduction> IR
87
Stages of adhesive capsulitis
Freezing
Frozen
Thawing
88
Describe freezing stage of adhesive capsulitis
Pain with movement
Generalised ache that is difficult pinpoint
Muscle spasm
Increasing pain at night and at rest
89
Frozen stage adhesive capsulitis
Less pain
Increasing stiffness and restriction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges if movement
90
Recovery stage of adhesive capsulitis
Decreased pain
Marked restriction with slow gradual increase in rom
Recovery is spontaneous but frequently incomplete
91
Pathology of adhesive capsulitis
Capsule adheres to humeral head and inferior fold sticks together
No intrarticular fluid
92
8 clinical identifiers early stage AC
Pain:
- strong component night pain
- pain with rapid unguarded movement
- discomfort lying on affected shoulder/pain easily aggravated
Movement:
- global loss active and passive rom, pain at end range all directions
- onset greater than 35 years of age
- end range
93
General management adhesive capsulitis
Very common to apply wait and see
| Often self limiting - 1.5-2 years but a percentage do not recover
94
Management adhesive capsulitis freezing phase
Pain relief
Heat , TENS
NO forceful movement
AAROM within limits if pain
95
Management adhesive capsulitis frozen and thawing phases
```
EOR joint mobs
Mwm
Muscle to
Strengthening scapular stabilisers
RC
posture control
```
96
Other treatment approaches for adhesive capsulitis
MUA/distension arthrograohy
97
Nerve injuries/entrapment a around the shoulder
Supra scapular nerve (burner/stinger syndrome)
Long thoracic nerve
Axillary nerve
Thoracic outlet syndrome
98
What is a primary shoulder impingement?
Within structures in the subacromial or subcoracoid space
99
What is secondary impingement?
External factors reducing size if subacromial space but still affect structures within.
Impingement symptomatic and present but source is something else dysfunctional within the shoulder complex
Joint laxity/restrictions (capsuloligamentous)
Motor control of GHJ Or SC joint
Posture and positions
100
What can be impinged in subacromial space?
Supra spinatus
is
Long head of biceps
Subacromial bursa
101
What can be a sub coracoid impingement?2
Subscap tendon and bursa in the coracohumeral space between lesser tuberosity and coracoid process
102
What do subacromial impingements often involve?
Repeated flexion tasks
103
Sub coracoid impingement symptoms
Flexion IR and horizontal flexion
Obriens tear position
Pain anterior portion of shoulder
Painful arc in flexion may be present
104
What impinges posteriorly?
IS and TM on posterosuperior border of the glenoid
105
Area of pain posterior impingement
Posterior acronym diffuse deep internal
106
Causes posterior impingement
```
Capsular laxity
Capsular tightness
Poor neuromuscular control
eccentric overload with ER
Pain reproduction in ER and and
```
107
What can occur with laxity and deficiency in passive restrains to motion of HOH with glenoid increases
Lack of HOH control
Excessive translation (anterior posterior or superior inferior)
Impingement can result
108
How can motor control cause secondary impingement
Scapular muscle imbalance:
- anchoring of GHJ muscles and line of force
- position if glenoid and also HOH
- -ability of HOH to clear the acromion during function
Rotator cuff weakness:
- failure to control HOH positions
- potential increases anterior or superior translation
- consequence = impingement
109
What can cause secondary impingement
```
Laxity
Joint restrictions
Motor control
Repetitive overload in sport
Posture and positioning
```
110
How can repetitive overload cause secondary impingement?
Fatigue of rotator cuff as centraliser of HOH - loss of control
111
What are the stages of impingement?
1. Oedema and haemorrhage
2. Compressive disease
3. Bony spurs/tendon ruptures
112
Stage 1 impingement
Oedema and haemorrhage
From mechanical irritation of tendons in overhead activities
Younger athletic patients
Reversible
113
Stage 2 impingement
Compressive disease :
Fibrosis and tendinitis
Repeated episodes mechanical inflammation
Results in thickening or fibrosis subacromial burse
25-40 yo
114
Stage 3 impingement
Bone spurs/tendon ruptures
Continued mechanical compression
Acromial architectures May be involved
115
Risk factor RC tears
```
Smoking
Hypercholesterolemia
Family history
A symptomatic tears progress
Pain highly correlated with progressive/increasing tear size
```
116
What is required for ideal scap movement
```
Trapezius - 3 portions
SA
Levator scap
Rhomboidal
Pec minor
```
Need to work in synchrony to elevate, upward rotate and ER scap for ideal glenoid position
117
Action Lower trapezius
Depress scap
Posterior tilt
ER
118
Serratus anterior
Anteriorly translates medial border of scapula
Upward rotatio
Posterior tilt
ER
119
In scapular dyskinesis loss of ability to achieve:
60 degree upward rotation
ER maintaining medial border flat against rib cage
Retraction
120
Not to be missed with shoulder pain
```
Tumour (bone tumour in the young)
Referred pain:
Diaphragm
Gall bladder
perforated duodenal ulcer
Heart
Spleen (left shoulder pain)
Apex of lungs
Thoracic outlet syndrome
Axillary vein thrombosis.
```
