Shoulder Flashcards
In full shoulder abduction how many degrees comes from GH joint abduction and how much comes from scapular rotation?
120 degrees from GH joint and 60 degrees from scapular rotation
How many muscular force couples are there?
3
deltoid-RTC
-Upper Trap-serratus ant
-ant/post RTC
Which should muscular force couple helps approximate the humeral head during shoulder abduction?
Deltoid-Rotator Cuff Force Couple
What muscles helps approximate the humeral head into the glenoid when the deltoid attempts to the elevate the humeral head during abduction?
Rotator Cuff musculature
What muscles forms a force couple with the upper trapezius?
What are the 4 main functions of this force couple?
Serratus Anterior
-maintain glenoid positioning while allowing serratus rotation
-maintain and efficient length tension relationship for the deltoid
-prevents impingement of the rotator cuff from the subacromial structures
-provides a stable scapular base enabling appropriate recruitment of the scapulohumeral muscles
What muscles form a force couple with thesubscapularis?
Infraspinatus and the teres minor
What is the kibler scapular slide test used for and how is it performed?
used to test for scapular instability and weakness
Use a measuring tape and measure the distance from a thoracic spinous process to to the inferior angle of the scapula, if the difference is more than 1-1.5cm it may indicate weakness or instability of the scapula
What nerve, if damaged or inhibited, would cause scapular winging?
Long Thoracic Nerve
What are the three types of scapular dysfunction?
inferior, anterior, and medial
What is the condition is commonly seen in patients who have inferior scapular dysfunction?
RTC impingement
What is antetilting and how does it relate to shoulder instability?
antetilting is a result of medial scapular dysfunction in which the scapula medially rotates allowing for less resistance of anterior humeral translation, resulting in increased risk of instability and dislocation/subluxation
What is the most common cause of superior scapular dysfunction?
RTC weakness and force couple imbalance
What are the 3 views that are part of a standard imaging order for the shoulder?
AP, scapular Y, and axillary views
How big of a gap between the acromion and top of the humeral head would indicate a subluxation or dislocation of the shoulder?
7-8 mm
Which populations are more at risk to develop adhesive capsulitis?
females with hypothyroidism
males with diabetes
Without intervention what is the clinical curse for adhesive capsulitis?
12-18 months with 4 stages and 40% of patients may reports symptoms 2 years later since onset
What are the four stages of adhesive capsulitis?
Pre-Freeze
Freezing
Frozen
thawing
A patient has decreased range of motion in their shoulder due to pain that has been gradual over the past 3 months, what stage of adhesive capsulitis does he fit into the best?
Stage 2 or Freezing stage
A patient has extremely limited range of motion but pain only at the end ranges of his movement and reports his symptoms have been present and getting worse fort about a year, what stage of adhesive capsulitis does this patient fit into the best?
Stage 3 or Frozen Stage
A patient reports they have pain at the end range of their shoulder motion and their sleep has been disturbed due to shoulder aching pain for about a month, what stage of adhesive capsulitis does this closely resemble?
Stage 1- Pre-Freeze
What criteria helps rule in adhesive capsulitis?
-age between 40-65
-gradual insidious onset of pain and stiffness
-stiffness that limits sleeping, reaching, grooming, etc.
-GH ROM limited, most notably ER
-IR is decreased as the shoulder is abducted
What criteria can be used to rule OUT a diagnosis of adhesive capsulitis?
-Normal PROM
-confirmed glenohumeral OA
-IR/ER that improves as arm is abducted
-familiar symptoms reproduced with palpation of the scapula
A patient presents with symptoms that are in line with adhesive capsulitis but the symptoms rapidly got worse and reached their peak in a matter of weeks rather than months, what is a more likely diagnosis?
Acute calcific tendinitis
What outcome measures get an A level recommendation in the CPG on adhesive capuslitis?
DASH and shoulder pain and disability index (SPDI)
What criteria fits into the ‘High Irritability’ classification for adhesive capsulitis?
NPRS over 7/10
Constant night pain or pain at rest
High reported disability on outcome scores
Pain occurring before end ranges of AROM or PROM
AROM significantly less than PROM
What criteria fits into the ‘Moderate Irritability’ classification for adhesive capsulitis?
NPRS between 4-6/10
intermittent night/rest pain
moderate disability reported on outcomes
Pain only at end range of AROM or PROM
AROM similar to PROM
What criteria fits into the ‘Low Irritability’ classification for adhesive capsulitis?
NPRS lower than 3/10
No night or rest pain
low reported disability
pain only with overpressure in PROM at end range
AROM is equal to PROM
What level of evidence is given for intraarticular corticosteroid injection for Adhesive Capsulitis and in what stage?
A level evidence if it is used with mobility exercise and works best in early stage but also helpful in more chronic cases
What level of evidence is patient education given in Adhesive Capsulitis and what should that education consist of?
B level and should consist of natural course of condition, activity modification, and how to match intensity to disease stage
What level of evidence is given for stretching that matches condition irritability for Adhesive Capsulititis?
B level but research is inconclusive of efficacy over other interventions
What are the 3 C level interventions for adhesive capsulitis?
Joints mobs of GH joint
heating modalities used w/ stretching
translational manipulation
For High Irritability Adhesive Capsulitis, what intervention are recommended? (modalities, home care, manual, etc.)
Modalities: heating and E stim
Home Care: education of activity modification and comfortable positioning
Manual: low intensity joint mobs
Mobility: pain free PROM and AAROM
For Moderate Irritability Adhesive Capsulitis, what intervention are recommended? (modalities, home care, manual, etc.)
Modalities: Heat and e-stim as needed
Home Care: progressive activities to gain motion without irritating tissues
Manual: moderate intensity mobs progressive into tissue resistance without irritating tissues and causing pain or inflammation
Neuromuscular re-education activities to improve GH movement with reaching
For Low Irritability Adhesive Capsulitis, what intervention are recommended? (modalities, home care, manual, etc.)
No modalities
Self Care: progressing to high demand ADLs
Manual: mobs into tissue resistance without pain
procedures to improve neuromuscular positioning of GH joint with functional tasks
What is Thoracic Outlet Syndrome?
a condition characterized by a group of symptoms that can have different causes involving one or more neuromuscular structures between the C spine and axilla
What are the 3 segments of the brachial plexus? What is contained in each?
supraclavicular-roots and trunks of nerves
retroclavicular-divisions of brachial plexus
infraclavicular- cords and branches of brachial plexus
What structures pass through the interscalene triangle?
C5-T1 nerve roots and trunks and subclavian artery
note the subclavian VEIN does not pass here
What structures pass through the costoclavicular space?
divisions of the brachial plexus pass through as do the subclavian artery AND vein
What structures pass through the subcoroid space?
brachial plexus cords pass through here and then form branches
subclavian artery and vein pass through but are called axillary vein and artery once they do
What site is the most common for subclavian vein compression?
costoclavicular space
What spaces can repetitive overhead movements cause compression as it relates to the brachial plexus?
costoclavicular space and subcoroid space
When do Subclavian artery and vein become axillary vein/artery?
after the structures pass through subcoroid space
What is the most common form of thoracic outlet syndrome?
Neurogenic TOS which is compression of the nerve of the brachial plexus
What is lower brachial plexus thoracic outlet syndrome? How is it diagnosed?
when nerves of the C8-T1 branches are pulled superiorly and patient has symptoms in C8-T1 distribution(medial arm and forearm N/T and weakness of the thenar muscles and finger flexors and abductors
Diagnosed by symptoms that resemble carpal tunnel but affect opposite side of the hand and radiculopathy has been ruled out
What is Upper thoracic outlet syndrome? How does it usually present?
compression of the C5-6 nerves with sensory changes of the lateral arm and forearm as well as lateral 2 digits and weakness of the shoulder abductors, elbow flexors, and wrist extensors
What is Venous Thoracic outlet syndrome? What provokes it?
compression of the subclavian vein (so it can only happen in subcoroid space or costoclavicular space
Provoked with repetitive upper extremity tasks such as throwing and associated with venous thrombosis
What is Paget Schroetter Syndrome?
an “effort thrombosis” which is a form of primary thrombosis in the subclavian vein at the costoclavicular junction and is usually seen in younger patients after repeated strenuous activity of the shoulders and arms
What are the symptoms of arterial thoracic outlet syndrome?
pain with upper extremity effort, easily fatigued, pallor, upper extremity coolness, and decreased distal pulse
What test can help differentiate arterial thoracic outlet syndrome for peripheral arterial disease?
Allen’s Test as well as screening comorbidities
What sites can be involved with arterial thoracic outlet syndrome?
all 3 spaces associated with TOS
What is the purpose of the Adson’s Test?
Tests for scalene tension and if it relates to TOS symptoms
What tests try to depress the shoulder with the arm at the side while palpating the distal radial pulse to test implication of the costoclavicular space?
Costoclavicular test and Halstead maneuver
What test can be used to relieve tension in the costoclavicular space?
passive shoulder shrug test
What symptoms should you look for to rule up a diagnosis of subacromial pain syndrome using the STAR should classification system? What signs help to rule it out?
RULE IN
-Impingement signs (Neer’s Hawkin’s Kennedy, Empty Can, etc.)
-painful arc
-atrophy/weakness
RULE OUT
-Significant ROM loss
-Signs of GH instability
What symptoms should you look for to rule up a diagnosis of Adhesive Capsulitis using the STAR should classification system? What signs help to rule it out?
RULE IN
-insidious onset of gradual and significant ROM loss with ER effected the most
RULE OUT
-if patient is under 40 years old
What symptoms should you look for to rule up a diagnosis of Shoulder Stability Deficits using the STAR should classification system? What signs help to rule it out?
RULE IN
-age under 40
-history of subluxation or dislocation
-positive relocation or apprehension signs
-generalized laxity
RULE OUT
-no history of dislocation or subluxation
-no signs of apprehension
Are the apprehension and relocation tests more specific or sensitive?
more specific but also have good sensitivity
What should treatment consist of for patient who are high irritability and have pain associated with local tissue pathology?
How does treatment change for moderate and low irritability?
High-activity modification, manual therapy and modalities
Mod-activity modification and progressive activity re-introduction
Low-progressive activity re-introduction with no modalities
What should treatment consist of for patient who are high irritability and have pain associated with central sensitization?
How does treatment change for moderate and low irritability?
for all irritabilities patient should be progressively re-introduced to PLoF
What should treatment consist of for patient who are high irritability and have neuromuscular weakness associated with non-use and deconditioning?
How does treatment change for moderate and low irritability?
High-AROM within pain free range
Mod-light to mod resisted exercise to fatigue in mid ranges
Low-mod to high resistance to end range
What should treatment consist of for patient who are high irritability and have neuromuscular weakness associated with poor motor control or neural activation?
How does treatment change for moderate and low irritability?
High-AROM in pain free range and consider NMES and biofeedback
Mod-Basic movement training focused on quality and precision rather than resistance
Low-high demand movement training
What is Primary External Impingement?
impingement directly related to the subacromial space such as an acromial anatomy anomaly or AC join bone spur
What anatomical acromial anomaly is correlated to increased risk of RTC tears?
Hooked
What are the 3 stages of Primary external impingement proposed by Neer?
1- Edema and Hemorrhage (RTC tendon is irritated due to overhead activity, mostly in younger population)
2- Fibrosis and Tendinitis (repeated episodes of mechanical inflammation and fibrosis of the subacromial bursa, usually happen between 25-40 years of age)
- Bones spurs and tendon rupture (repeated mechanical pressure leads to tears, bicep tendon lesion, and AC joint abnormalities)
What is Secondary External impingement?
mechanical external impingement caused by instability and not morphology that can be due to multiple issues
What is internal impingement?
Impingement that is associated with the joint articulation most commonly due to posterior impingement with overhead throwing athletes where the RTC catches the glenoid at the cocking phase of a throw
What is the CPR for subacromial impingement?
Is this CPR more sensitive or specific?
-(+) Hawkins Kennedy
-(+) Painful Arc
-(+) pain with shoulder ER MMT or lag sign
Specific
What are intrinsic factors related to RTC tears?
age
collagen thinning and decreased vascularity
genetics
How to RTC tears typically present?
-anterior or posterior shoulder pain that may be worse at night
-loss of strength and pain wakes them up at night
What is the Park et al CPR for RTC tears?
Is this CPR more specific or sensitive?
-(+) painful arc
-weakness or pain with infraspinatus MMT
-(+) drop arm sign
specific (2/3=69% and 3/3=91%)
What percent of the population over the age of 65 that is asymptomatic has a RTC tear?
55%
What is calcific tendonitis?
a condition with poorly understood etiology where tenocytes transform into chondrocytes and deposit calcium in tendons which then has be healed by the body
How does Calcific tendonitis typically present?
-severe spontaneous shoulder pain that is worse in the morning
-pain in anterior shoulder near bicipital groove or posterior shoulder inferior to the spine of the scapula
-loss of AROM and PROM as well as weakness
-resolves spontaneously
What is Parsonage Turner Syndrome?
How does it Present?
an autoimmune response following infection or vaccination or surgery that is more common in men and deal with nerve pain and the brachial plexus with an unknown etiology
-constant severe unilateral shoulder girdle pain that can extend into the trap and down the arm
-neural issues such as weakness and sensory deficits
-pain resolves in 1-2 weeks
-constant pain that is worse at night
Diagnosed with an EMG study
What is the TUBS acronym for shoulder instability?
Traumatic
unilateral
bankhart lesion
surgery
What is the AMBRI acronym for shoulder instability?
Atraumatic
multidirectional
bilateral
rehabilitations
inferior capsular shift
What is the most common direction for dislocation?
Anterior (95% of cases)
Anterior shoulder dislocation affect which ligament? What movements compromise this ligament?
antero-inferior glenohumeral ligament
ABD and ER
What two tests help diagnose anterior instability? What sign makes these tests more specific?
What is the most specific test for anterior instability?
Apprehension and relocation tests
apprehension is more specific than pain
anterior release or surprise test=most specific
What position do posterior shoulder dislocations mostly occur in?
Which ligament is compromised?
What are the two most common causes of post. shoulder dislocation?
flexion/internal rotation positions
posterior-inferior glenohumeral ligament
trauma (2/3) and seizures (1/3)
What is the most useful special test for posterior shoulder instability diagnosis?
posterior apprehension test
Are inferior dislocation mostly due to trauma or atraumatic?
What is the best special test for inferior instability?
Atraumatic (AMBRI)
Hyperabduction test (examiner applies inferior force to GH joint and abducts the arms, test is positive if apprehension is noted before 105deg.)
Why are sulcus sign and load and shift tests not suggested to be used to test for shoulder instability?
Because these test for joint laxity not stability
What is the Beighton scoring system?
How is it scored?
a scoring system for global hypermobility
9 points possible
1 point for each of the following
-little finger extends to over 90deg in MPC joint
-if thumb touches forearm in wrist flexion
-elbow hyperextension beyond 10deg
(all of the above methods are done bilaterally and 1 point is for each side so 8 points possible)
-If patient can stand and put their palms on the floor with their knees straight
5/9 is positive for adults
6/9 is positive for adolescents
What is a Bankart Lesion?
What is a bony bankart lesion?
an avulsion fracture of the anterior-inferior glenohumeral ligament due to anterior shoulder dislocation
bony bankart=fragment of glenoid is involved
What is a reverse Bankart lesion?
an avulsion fracture of the posterior-inferior GH ligament during a posterior dislocation of the shoulder
What is a Hill-Sach’s lesion?
What is a Reverse Hill-Sach’s lesion?
a compression fracture of the posterior-superior humeral head during anterior-inferior dislocation when the articular surface of the humerus hits the glenoid rim
Called a reverse HS lesion if it was a posterior dislocation that affected the anterior-superior-medial surface of the humeral head
What are SLAP lesions?
What symptoms are common?
superior labrum anterior-posterior tears that can involved the long head of the biceps and are usually due to trauma or repetitive overhead activity
Sx include vague deep shoulder pain, a feeling of a dead arm, and pain w/ overhead throwing
What is a type 1 SLAP lesion?
isolated fraying of the superior labrum without detachment of the labrum and without biceps involvement
What is a type 2 SLAP lesion?
detachment of superior labrum and biceps tendon together from the superior glenoid (almost looks like the biceps tendon pulled the labrum from the glenoid)
What is a type 3 SLAP lesion?
a bucket handle tear of the labrum only where the labral tissue is completely detached and possibly flapped over into the glenoid
What is a type 4 SLAP lesion?
bucket handle tear of superior labrum AND biceps tendon
What findings justify a positive result during an OBrian’s test? (Active compression test)
Is this test more specific or sensitive?
positive if the there is a deep vague shoulder pain when an inferior force is resisted when arm is flexed to 90 and adducted to 15deg
also positive if you repeat this measure but with palm up and there is less pain
Sensitive
What justifies a positive findings for Speed’s test?
Is this test more specific or sensitive?
pain when performing a shoulder flexion MMT with their palm up
Specific
What justifies a positive findings for Anterior slide test?
Is this test more specific or sensitive?
positive if there is a painful clunk patient has their hand on their hip and examiner applies supero-anterior force their the humerus via their elbow
specific
What justifies a positive findings for Crank test?
Is this test more specific or sensitive?
positive if their is pain with or without a clunk when patient is supine with their shoulder flexed and elbow bent and examiner applies force into the humerus via the elbow as the arm is IR/ER’d
specific
What are the three main ligaments involved with AC joint sprains? Which is the first to be injured?
What muscles provide stability to the AC joint?
acromioclavicular ligament-envelopes the AC joint and is the first to be injured
coracoclavicular ligament which extends from the coracoid to the clavicle and is technically two ligaments (the trapezoid and the conoid ligaments)
Trapezius and deltoid muscles
What are the main stabilizing ligaments for the AC joint?
trapezoid and conoid ligaments which form the coracoclavicular ligament
What is a type 1 AC joint sprain using the Rockwood Classification?
How is it diagnosed?
sprain but no tear of the acromioclavicular ligament only with no elevated of the clavicle to acromion
diagnosed with history of symptoms, MOI, TTP over ACJ, positive O-brain’s or cross body adduction test since no radiographic evidence will be present
What is a type 2 AC joint sprain using the Rockwood Classification?
How is it diagnosed?
AC ligament and joint capsule will be ruptured but coracoclavicular ligaments will be sprained but not ruptured leading to an elevation of the clavicle on the acromion but not past the superior border of the acromion
imaging used to diagnose though there may be a very feint step off deformity
What is a type 3 AC joint sprain using the Rockwood Classification?
How is it diagnosed?
a rupture of the AC ligament and full rupture of the coracoclavicular ligaments with significant displacement of the clavicle above the superior border of the acromion
there is less than twice the normal distance between the clavicle to coracoid process found in imaging
Obvious Step off deformity
What are Type 4-6 AC joint sprains using the Rockwood Classification?
Type 4- clavicle is posteriorly displaced into the trapezius muscle
Type 5-clavicle is elevated greater than 2x the normal distance between clavicle and coracoid process
Type 6-inferior displacement into the subcoracoid space that involves neural injury
Which level of AC joint is surgery recommended?
types 4-6 and possibly 3
What is the SICK scapula?
A muscular fatigue syndrome of the periscapular musculature where you may see one or more of the following
-Scapular malposition
-Inferior medial border prominence
-Coracoid pain and malposition
-Dyskinesia of scapular
movement
