Shoulder Flashcards
Hill-Sachs Lesion
- Compression fx of the posterosuperior aspect of the humeral head
- occurs in anterior-inferior shoulder dislocation
Reverse Hill-sachs
- compression fracture of the anteriosuperomedial side of humeral head
- occurs with posterior shoulder instability
AC ligament
- attach at anteromedial edge of acromion to lateral edge of clavicle
- provided stability in anterior posterior direction
CC ligament
- conoid ligament and trapezoid ligament
- provide restraint to superior inferior surfaces
- conoid > trapezoid
Rockwood AC Type I
- Sprain to AC ligament, stretched, maybe partially torn
- no displacement
Rockwood AC Type II
- AC ligament is completely torn
- CC ligaments stretched byt intact
- mild displacement
Rockwood AC Type III
- AC and CC are ruptured
- complete separation of ACJ
- displacement noted
T/F: Anterior dislocations at clavicle due to indirect forces outnumber posterior dislocations
T
What is often implicated in idiopathic frozen shoulder
- axillary pouch
- coracohumeral ligament
- rotator cuff interval
Two labels of GH instability
TUBS
AMBRI
TUBS
traumatic
unilateral
bankart lesion
surgery
AMBRI
atraumatic
multidirectional
bilateral
rehabilitation
inferior capsular shift
Bankart lesion
avulsion of the anterior band of the inferior GH ligament that occurs with the labrum
Reverse bankart lesion
capsulolabral lesion involving the posterior labrum and posterior inferior GH ligament
What can lead to SLAP lesion in overhead athletes
high eccentric biceps activity
Shortest distance between acromion and supraspinatus happens where
30-70 degrees of elevation
SAI does not happen beyond this
At what age does RC vascularity decrease
40 years old
6 mm responsible for stabilization at scapulothoracic joint
- trapezius
- SA
- Levator scapulae
- rhomboid major and minor
- pec minor
scapulohumeral rhythm
2:1 ratio comprised of 60 degrees of scapular upward rotation and 120 degrees of GH joint movement
Scapular muscle imbalance and altered motor control believed to contribute to dyskinesis
- excessive upper trapezius activation
- decreased or delayed activation of lower and middle trap and SA
neurological causes to scapular dyskinesis
- cervical radiculopathy
- long thoracic nerve palsy
- accessory nerve palsy
Nociceptive pain pattern for subacromial structures and GH joint disorder are located wear
distal to the acromion in the lateral deltoid region
Pain from ACJ is located wear
- top of the acromion surrounding the ACJ and may extend to anterior aspect of the shoulder
Adhesive capsulitis - primary
hx and sx
- persistent pain anterior-lateral shoulder region accompanied by inability to sleep due to pain and gradual loss of motion due to pain
- higher risk in females, age 40-65, presence of diabetes and hypothyroidism
GHJ OA
hx and sx
- gradual onset of pain and associated loss of motion
- 60 or older
- may complain of crepitus or catching with end range motions and stiffness that is worse in the morning
Subacromial pain syndrome
hx and sx
- anterior/lateral shoulder pain
pain with motions at or above shoulder height - complains of pain with mid-range active shoulder elevation (painful arc)
- pain increases at night
rotator cuff tear
hx and sx
- anterior/lateral shoulder pain
- loss of strength
- pain that wakes the patient during sleep
- pain that is worse at night
- age 40 or greater
anterior instability/labral tear
hx and sx
- anterior shoulder pain, apprehension, pain in positions of end range shoulder abd and ER
- hx of anterior/inferior trauma
- recurrent anterior/inferior subluxations or dislocations
- joint clicking/clunking
- joint locking
- hx of dead arm syndrome
posterior instability
hx and sx
- complaints of instability, apprehension, pain in positions of combined shoulder flexion and horizontal add with posterior directed force on humus (pushing or closed chain activities
- hx of trauma with or without recurrent subluxations and dislocations
SLAP lesion
hx and sx
- deep anterior shoulder pain with clicking/clunking/joint locking
- pain with throwing or biceps loading (shoulder flexion and arm supination)
Posterior internal impingement
hx and sx
- posterior shoulder pain during combined shoulder abduction and ER with horizontal plane hyperabduction
- overhead athletes complain of reduced performance
long head of biceps tendinopathy
hx and sx
- anterior pain isolated to long head of biceps in the bicipital groove particularly with shoulder flexion and arm supination
AC joint arthropathy/injury
hx and sx
- shoulder pain at top of shoulder near AC joint increases with end-range shoulder elevation or horizontal add
- hx includes heavy weightlifting, hx of trauma with contact force that displaced shoulder girdle inferiorly
- visual deformity at top of shoulder may be apparent
high irritability
- pain >7
- constant night or rest pain
- high disability level
- pain limits ROM (active>passive)
moderate irritability
- pain 4-6
- intermittent night or rest pain
- moderate disability
- little discrepancy with passive and active with pain at end range
low irritability
- pain <3
- no resting or night pain
- minimal pain at end range with OP
- active = passive
common red flags for shoudler
- tumor
- infection
- visceral pathology
- rheumatological
not so common
- polymyalgia rheumatica in patients >60
- acute long thoracic, spinal accessory, or other nerve palsy
- parsonage-turner syndrome
- visceral causes that irritate mediastinal pleura pericardium
Positive findings to rule in subacromial pain syndrome
- impingement signs (neer, hawkins, jobe (empty can)
- painful arc
- pain with resisted ER
- positive long head of biceps tear
negative findings to rule out subacromial pain syndrome
- significant loss of passive motion
- apprehension with instability tests
positive findings to rule in substantial rotator cuff tendon tear
- age >60
- lag signs
- weakness
- atrophy
negative findings to rule out substantial rotator cuff tendon tear
- significant loss of passive motion
- apprehension with instability tests
positive findings to rule in primary adhesive capsulitis
- spontaneous progressive pain
- loss of motion in 2 or more planes with ER most limited
negative findings to rule out primary adhesive capsulitis
- imaging for GHJ OA
- age <40
normal passive GHJ motion
positive findings to rule in GHJ instability
- age <40 with atraumatic onset
- hx of subluxation or dislocation
- apprehension test
- relocation test
- generalized or systemic laxity (>5/9 beighton scale)
- SLAP lesion tests
negative findings to rule out GHJ instability
- no hx of dislocation or subluxation
- apprehension with instability test
gold standard imaging for osseous lesion, subtle fracture, erosive changes to clavicle, AVN, labroid, RC, and bicep muscle
MRI
when is MRA indicated
- atraumatic instability, labral tear, small RCT
CT for shoulder
- can see fracture/fracture-dislocation
- prosthetic joint
concordant sign
movements or positions that reproduce the patients primary shoulder complaint
suprascapular neuropathy
- common in overhead athletes
- occurs with compression at spinoglenoid notch associated with paralabral cyst and affecting only infraspinatus
Cervical Radiculopathy cluster
- same side cervical rotation ROM less than 60
- positive median nerve upper limb neurodynamic test
- relief with distraction
- positive spurlings
what is shoulder innervated by
C5 and C6 (subscapular, supraspinatus and axillary)
where is shoulder pain located
below acromion in deltoid region
where is ACJ pain located
superior aspect of shoulder in C4 distribution and is more focal
scapular assistance test
- performed by manually inducing scapula upward rotation and posterior tilt during active shoulder elevation
positive
- reduced scapular posterior tilt and decreased pec minor muscle length
scapular reposition test
- performed by the therapist manually inducing scapular posterior tilt concurrent with patient being tested with an isometric empty or full can resisted shoulder elevation test
positive
- reduction in symptoms by 2 or more points
GIRD
- occurs when the loss of IR exceeds the increase in ER noted by either a loss in total arc of motion of >5 or a loss of IR ROM of 10-25 compared to non dominant shoulder
- risk for overhead athletes
what position provides the most strain of posterior capsule
IR in low angle of flexion (60)
tests to rule in subacromial pain syndrom
3/5
- neer
- hawkins **
- jobe (empty can)
- painful arc **
- pain with resisted ER **
+LR 2.93 -LR .30
** +LR 10.56 -LR .17
full thickness RCT
- age >65
- pain at night
- weakness in ER
SP 94.4% +LR 9.8
Drop Arm test
- patient in standing or sitting, shoulder is placed in 90 abduction. examiner removes arm support
- Positive if arm drops
tests supraspinatus or infraspinatus
SN 44
SP 98
+LR 26.1
-LR .6
ER lag sign
elbow at 90 degrees flexion, examiner passively moves arm to 20 degrees of scapular plane abduction and near max ER. Patient has to retain position for 10 seconds
- POSITVE if patient is unable to hold position
SN 69
SP 98
+LR 49
-LR .02
ER at 90 (hornblower’s sign)
-elbow flexed to 90, examiner passively elevates arm to 90 in scapular plane and externally rotates shoulder and releases forearm (holds elbow otherwise)
- POSITIVE if patient is unable to hold
infra
SN 21
SP 92
+LR 2.6
-LR .86
teres minor
SN 95
SP 92
+LR 12
-LR .05
tests for subscapularis tendon tear
- IR lag sign
- lift off
- belly press
- bear hug
IR lag sign
- therapist passively places patients hand behind the lumbar region. Hand is passively lifted away from lumbar spine and support is released
- POSITIVE when patient is unable to maintain position
SN 97
SP 96
+LR 24
-LR .03
lift off test
- place hand of shoulder on back and ask patient to internally rotate arm to lift hand off back
- POSITIVE if patient is unable to lift arm off back or is performed by extending elbow or shoulder
SN 62
SP 98
+LR 31
-LR .39
belly press test
- arm at side and elbow flexed to 90, have patient press palm into belly
- POSITIVE if inability to attain position of arm in abduction, indicated by elbow staying posterior to thorax
SN 40
SP 98
+LR 20
-LR .61
bear hug test
- passively positioning shoulder in 90 of flexion as patient internally rotates to touch top of opposite shoulder. patient tries to hold starting position by means of resisted IR as examiner pulls hand away from shoulder with ER force applied perpendicular to forearm
SN 60
SP 92
+LR 7.5
-LR .32
tests for anterior instability
- apprehension **
- relocation **
- surprise **
**
SN 81
SP 98
+LR 39.7
-LR .19
athletes with internal impingement
- gradual onset of symptoms and pain noted in the cocking position of throwing
- can occur with shoulder ER and abduction, exacerbated by hyperabduction
anterior apprehension test
- positive with reproduction or pain or apprehension
pain
SN 50
SP 56
+LR 1.1
-LR .89
apprehension
SN 72
SP 96
+LR 20.2
-LR .29
relocation test
- POSITIVE when pain or apprehension felt with apprehension test is reduced or eliminated
pain
SN 30
SP 90
+LR 10.4
-LR .20
apprehension
SN 81
SP 92
+LR 3.0
-LR .77
Surprise test
positive when pain is when pain or apprehension is reproduced
SN 64
SP 99
+LR 58.6
-LR .37
posterior apprehension test
- patient supine, elbow at 90, shoulder is flexed to 90 and adducted. therapists applies posteriorly directed force via long axis of humerus
- Positive with apprehension
SN 19
SP 89
+LR 19
-LR .82
hyperabduction test
- tests for inferior instability
- therapist stands behind patient and applies an inferiorly directed force on scapula and passively abducts shoulder to 90 with elbow flexed.
- POSITIVE when apprehension or increased laxity with >105 degrees of abduction
SN 67
SP 89
+LR 6
-LR .37
AC joint test
- combination of pain with palpation and a positive O brien active compression test with pain located at top of shoulder
SP 97
SN 7
+LR 2.08
Paxino’s
- placing the examiners thumb under the posterior lateral aspect of the acromion and index and middle fingers of the same hand on the superior aspect of the clavicle
- examiner then applies pressure in an inferior direction on the clavicle while pushing the acromion anteriorly and superiorly
- POSITIVE findings are pain and hypomobility.
Primary adhesive capsulitis
- spontaneous loss of shoulder motion and specifically limitations in shoulder ER ROM
- more common in women 40-65, diabetes, hypothyroidism, autoimmune disease
red flag pathologies that mimic Adhesive capsulitis
joint infections
septic arthritis
malignancy
inflammatory arthropathy
secondary adhesive capsulitis
result of a period of immobilization
when is surgery recommended following adhesive capsulitis
3-6 months of failed care
latarjet surgery
non-anatomic procedure that involves transferring the bone off the distal end of the coracoid to the anterior aspect of the glenoid to augment the bone loss and provide stability
Which muscles of the shoulder dynamically resist excessive anterior translation of the glenohumeral joint?
infraspinatus and teres minor
You note that the patient also demonstrates winging of the medial border of the right scapula. This is most apparent when bearing weight through the right upper extremity but is also noticeable with shoulder forward flexion and flexion in the scapular plane. Which of the following exercises would best address this form of scapular dyskinesia?
Push-up position with end range scapular protraction, elevated as necessary to perform the exercise pain-free.
Which of the following surgical procedures involves overlapping and shortening of the subscapularis muscle?
Putti-Platt
This procedure advances the subscapularis tendon laterally over the humerus, thus tightening the anterior capsule.
Stack-Manson
Accessory motion at the sterno-clavicular joint during arm elevation includes _________.
Inferior glide of the clavicle
The primary restraint to inferior translation of the humerus at 90 degrees of gleno-humeral abduction is the ______________.
Inferior glenohumeral ligament
restraint to inferior humeral translation when the arm is positioned at zero degrees elevation.
Superior glenohumeral ligament
The capsular pattern for the glenohumeral joint is _____________.
External rotation, abduction, internal rotation
The best position to strengthen the supraspinatus for a patient with sub-acromial impingement syndrome is _____________.
The “full-can” position
axillary nerve
- innervates deltoid and teres minor
lateral scapular slide test
used to determine scapular position with the arm abducted 0, 45, and 90 degrees in the coronal plane. Assessment of scapular position is based on the derived difference measurement of bilateral scapular distances.” Patients with suspected scapular weakness have increased measurement values on the involved side
primary versus secondary impingement
Primary subacromial impingement is due to mechanical narrowing of the subacromial space, while secondary subacromial impingement is due to a functional disturbance
Speeds test
- tests for biceps pathology or SLAP
Which motion would be the most pathognomic for the AC joint as a primary pain generator?
Horizontal adduction
