Shoulder Flashcards
In volleyball: what type of serve creates the most IR torque?
Jump serve
then. ..
- Spike, Float serve, and roll shot
Pec Major
lat & med pectoral nerve; C5-T1
Which pitches in order from most to least forces and torque generated?
Fastball, curveball, slider, changeup
the fastball and curveball require more rotational movements, so more forces and torque are generated.
most Serratus EMG exercises
Prone Y = 97% EMG
prone ER 90 deg abd = 79% EMG
scaption = 61% EMG
prone T = 53% EMG
prone T + ER = 56%
wall flexion = 13
most force to shoulder during what throwing phase
deceleration
,Subclavius
nerve to subclavius, C5-6
Serratus anterior
long thoracic; C5-7
Trap
Spinal accessory nerve (XI), C3-4; XI, C3-C4
Lat
thoracodorsal nerve; C6-8
Levator scapulae
dorsal scapular nerve, C3-5
Rhomboids (minor & major)
dorsal scapular nerve, C4-5
subscap
Upper subscapular and lower subscap nerves, C5-6
supraspinatus
suprascapular nerve, C5-6
infraspinatus
suprascapular nerve, C5-6
Teres minor
axillary nerve, C5-6
deltoid
axillary nerve, C5-6
teres major n
lower subscapular nerve, C5-7
coracobrachialis
musculocutaneous, C5-7
Hills sachs lesion
depression fracture in posterolateral humeral head due to impaction of humeral head against anterior inferior glenoid rim
Hill sachs lesion Grading
I: defect in articular surface but not including subchondral bon
II: lesion includes subchondral bone
III: large defect in subchondral bone
Bankart lesion
lesion of anterior aspect of labrum due to repeated anterior subluxation/dislocation
humeral avulsion of IGHL
RTC special tests: highest SN
empty can, full can (pain & weak), lateral jobe (tear), shoulder shrug (tendinopathy > massive tear), whipple
RTC special tests: highest SP
ER lag sign for tear > tendinopathy, lift off (tendinopathy higher SP), lateral jobe (tear)
Supraspinatus special testing
Drop arm: .93 SP tendinopathy
Cross body .75 SN tendinopathy
Empty can 1.0 SP weak/pain
ER lag: .91+ SP tear
full can >.8 SN
painful arc .96 SN tear
HK .8-.77 SN tear
teres minor special testing
ER lag (tear) 1 SN, .93 SP
infraspinatus special testing
ER lag .97 SN/.93 SP
resisted ER (weak)=- tear .84 SN
subscap special testing
belly press, IR lag, resisted lift off (weak)
CPR for full thickness RTC
- painful arc
- drop arm
- infraspinatus muscle test
also:
1. age >65
2. weakness in ER
3. night pain
CPR for subacromial impingement
- positive HK
- painful arc
- infraspinatus MMT
posterior/internal impingement
apprehension (posterior)
posterior impingement test
labral special testing
speeds (.78 SP)
anterior slide (.86 SP)
crank (.75 for SLAP)
yergasons (.95 SP SLAP)
compression rotation (.78 SP)
dnyamic labral shear (.89 SN)
passive compression (.82-.86 SN & SP)
passive distraction (.94 SP)
active compression- lower SN/SP
labral CPR
-compression rotation AND apprehension AND speeds
-anterior slide AND crank
-apprehension AND relocation
Instability testing/CPR
- apprehension
- relocation
- anterior drawer
biceps tendinopathy
bear hug .79 SN
upper cut .78 SP
yergasons .78-.89 SP (resisted supination w/ elbow flexed at 90 deg)
Speeds also
adhesive capsulitis- risk factors, treatment
- presence of comorbidities (DM, thyroid)
- 40-65 yrs, female, previous episode in other side
intervention level of evident:
-steroid injection: A
-patient education, stretching: B
-modalities, joint mob, manip: C
Axillary nerve
originates at brachial plexus, through quadrilateral space, to deltoid/teres minor
site of entrapment: humeral head compresses with abduction; compression in quad space; dislocation; pressure through axilla
axillary nerve
-brachial plexus through quad space to deltoid/teres minor
-motor deltoid/teres minor
-entrapment: humeral head in extreme abd, axilla, shoulder dislocation, compress in quad space
long thoracic nerve
merge of C5-7 travels between clavicle & first rib, through axilla. motor to serratus
-entrapment: shoulder traction; shoulder depression w/ contralat cervical flexion; prolonged compression “backpackers palsy”
median nerve
brachial plexus in anterior arm, antecubital fossa nerve passes through radial tunnel, runs between 2 heads of pronator muscles, under FDS through carpal
motor issues: weak wrist flexion, no IP flexion of thumb/index/middle digits
motor issues: injury at wrist- weak thumb abd no motor deficit
site of entrap: radial tunnel, within pronator teres, under FDS, carpal tunnel
musculocutaneous
C5-7 into lateral cord of plexus, through axilla, under coracobrachialis, through biceps and under deep fascia at elbow.
radial
brachial plexus–>axilla -> posterior arm at spiral groove of humerus, down anterior arm through radial tunnel, divides into super ficial/deep branches
motor loss at axilla- weak elbow flexion, wrist/digit, supination weak
at radial tunnel- forearm pain but no motor loss
spinal accessory
motor loss- upper trap
entrapment: superficial cose in posterior cervical or under trap
suprascapular n
through posterior triangle, across superior scap through scap notch, down posterior scap across scap spine to supra/infra
motor loss of infra/supra, sensor loss to AC/GH joints
entrapment under transverse scapular ligament suprascapular notch
often assoc with posterior capsule tear
ulnar n
brachial plexu down anterior arm, above medial epicondyle, passes to posterior compartment into cubital tunnel, into guyon canal, splits into deep and superficial branches (deep motor, sf sensory)
entrapment: cubital tunnel, MCL deficiency, guyon canal
quadrilateral space
syndrome: compression of the axillary nerve and posterior humeral circumflex artery in the quadrilateral space.
location: lateral to triangular space and medial to triangular interval
boundaries
superior - teres minor
inferior - teres major
medial long head of triceps brachii
lateral - surgical neck of the humerus
contents:
**axillary nerve (C5 nerve root, posterior cord)
posterior circumflex humeral artery
posterior triangle/ triangular space
Borders
inferior: teres major
lateral: long head of triceps
superior: lower border of teres minor
Contents:
scapular circumflex artery
triangular interval
Borders
superior: teres major
lateral: lateral head of the triceps or the humerus
medial: long head of the triceps
Contents
profunda brachii artery
radial nerve
clavicle fracture dislocation
mid shaft most common fracture
if displaced posteriorly- cupula of lung most at risk
RTC least likely to succeed with PT
grade II bursal sided tear
rotator cuff interval
subscap & supraspinatus
SLAP testing- best test to confirm
-pitcher- biceps load I
-compressive injury: active compression, clunk
-traction injury: speeds
parsonage turner syndrome
sudden onset of shoulder and upper arm pain followed by progressive (worsening over time) weakness and/or atrophy of the affected area
TOS
borders:
-scalene triangle- anterior/middle scalene attach to first rib
-costoclavicular space- 1st rib & clavicle
-pec minor space
types: arterial, venous, congenital (rib at C7)
-arterial: rest pain worse with activity, cold/pale into hands, ischemia signs
TOS special tests
ROOS- 90/90 3 min open/close hands
Adsons- radial pulse, rotate head towards arm and tilt back, see if pulse disappears
-Allen test- 90/90 , turn head away and see if pulse disappears
Little league shoulder
microtrauma from throwing/poor mechanics
typical 11-13
retroversion & IR deficit- some changes are normal, occur around this age
fatigue & overuse #1 risk factor
Sprengel deformity
congenital elevation of hypoplastic scapula
often associated with other issues- Klenfeil (C spine fusion of 2 vert)
sprengel deformity - scapular malposition classification
*results in inability to actively abduct
1: level shoulders, not visible when dressed
II: lumbar in web of neck when dressed. superomedial angle between T2 & C5
III: shoulder elevated 2-5cm, deformity easily seen, medial angle above transverse apophysis ofC5, surgery
IV: superior angle of scap near occipit, surgery
clavicle fracture
middle shaft: 80%
group II: distal third
group III: medial third
static stabilizers of shoulder
-GH capsule
-rotator interval- spcae between sup border of subscap to anterior margin of supra
inferior/posterior stability, large interval in MDI
-SGHL, MGHL, IGHL
Superior GH ligament
limits ER at 0 deg abd
prevents inferior humeral head sublux
MGHL
limits anterior translation at ER 45 deg abd
IGHL
3 bands- post/ant/inf- stability at 90 deg abd
-anterior band: restricts abd/ER, fans out like hammock *strongest
-posterior: relatively thin,blends with RTC tendons, prevents posterior sublux
SLAP grades
I: superior labrum frayed
II: frayed and detached, anchors often needed
III: bucket handle tear, displaces into joint, biceps attached
IV: bucket handle tear displaced, biceps subluxes into joint
AC joint anatomy, grade injuries
coracromial arch- prevents superior HH displacement. SA space 10mm
stability- conoid & trapezius ligaments, coracromial ligament
6 grades:
I- sprain AC, ligaments intact
II- AC joint disrupted <50% displacement, sprain ligaments
III- AC & CC ligaments disruped, AC joint dislocated, CC space greater than normal, deltoid/trap detached from distal clavicle
IV: all of above plus clavicle displaced
V: all ligaments disrupted, bigger disparity between clavicle & scap (100-300%)
VI: surgery needed
throwing phase most likely to have pain
-Max ER - 90 deg abd, ER 180 deg, high IR/anterior force
-ball release
swimming phases, muscle involvement
-pull through, recovery, glide phases
-early phase- pec
-late pull through- high lat activity
-SA active in entire stroke
throwing muscle EMG activity
-late cocking- subscap 99%, SA 106%
-acceleration: subscap 115%, lat/triceps/pronator >80%
-decel: low trap 78%, teres minor 84%, FCU 77%
muscle EMG for common exercises:
-sidelying ER
-prone HABD at 120 deg, prone ER 90 deg
-SA exercises
-s/l ER: infra, teres
-low trap & mid trap: prone HABD 120 deg/prone ER 90 deg
-SA: push up plus, dynamic hug, supine serratus punch
clavicle fracture locations
middle 1/3 = 80%
distal 1/3 = 15%
proximal/middle 1/3 = rare
clavicle fracture classifications
for distal 1/3:
I: non displaced
II: displaced coracoclavicular lig –> upward dislocation of proximal segment
III: involves AC joint
shoulder dislocation - Quebec decision
age 40 + humeral ecchymosis
age 40 + first episode
<40 and MOI other than a fall
