Shoulder Flashcards
What are intrinsic factors of RTC tendinopathy?
Tendon degeneration due to age
neovascularization
change in vascularity with age
thinning of tendon and increased thickness of the structure
fatty infiltration
what are extrinsic factors of RTC tendinopathy?
abnormal scapulohumeral rhythm
shortening of posterior/inferior structures and pec minor
thoracic kyphosis
abnormal muscle activation patterns of RTC and scapular stabilizers
osseous changes to the AC joint or coracoacromial ligament due to overuse
What are the 3 types of shoulder impingement syndrome (SIS)?
- subacromial impingement
- intrinsic impingement
- internal impingement
what is subacromial impingement?
RTC tendons on the bursal side become comprssed in the subacromial space
what is intrinsic impingement?
tendon degeneration associated with age, shoulder muscle dysfunction, and overuse of the shoulder
what is internal impingement?
compression of the articular side of the infraspinatus tendon between between the superior-posterior glenoid rim and the head of the humerus when positioned in 90deg external rotation and 90deg abduction. It is associated with extrinsic factors and commonsly seen in overhead athletes. Sx is pain in the RTC
What is Glenohumeral Internal Rotation Deficit (GIRD)?
A type of internal impingement. PROM will reveal excessive ER and limited IR with an asymmetry of 25deg or more btwn involved and uninvolved sides
During functional testing, what symptoms are associated with supraspinatus impingement?
pain and weakness with abduction and external rotation during resisted isometric testing
What is the Hawkins-Kennedy test?
test of subacromial impingement
client in 90deg scaption or forward flexion, with elbow flexed, arm is passively move into IR
What is Neers Impingement Test?
test of subacromial impingement
place client in end-range flexion with slight IR and provide overpressure
what is Yergason’s test?
a test of involvement of the long head of the biceps in subacromial impingement
resisted elbow flexion with supination
What is the test for posterior internal impingement?
internal impingement between supra and infraspinatus and the posterior superior portion of the glenoid labrum
client is supine in a 90/90 throwing position and overpressure is applied toward more ER and extension
positive test is pain in posterior shoulder
What are the 3 progressive phases/goals of non-operative rehab for SIS?
Progressions are based on gradual tendon loading and include:
1. decreasing pain and increasing ROM through pain relief modalities and manual techniques, taping, activity modification, postural education, & isometric ther ex for scapular stabilizers and RTC in pain-free tolerance
2. increase ROM and soft tissue extensibility while continuing to decrease pain through pec minor and posterior capsule stretching, job mob to GH and scapulothoracic joints, and isotonic exercise for RTC and scapular stabilizers
3. Progressive strengthening and proprioceptive retraining once strength is 4/5 manual testing or equal to uninvolved side and there is normal GH rhythm
What are the 3 phases of rehab afer acromioplasty or subacromial decompression (SAD)?
Phase I: 0-2 weeks, decrease pain and increase PROM, pendulum exercises, wear sling between exercise
Phase 2: 2-6 weeks, manage pain, increase PROM, progress A/AAROM, sling as needed
Phase 3: 6-12 weeks, increase to full AROM, strengthen stabilizers for retrurn to function, full end-range AROM and PROM, open and closed chain kinetic training, plyometrics and proprioception drills
3 symptoms associated with RTC tear
- weakness with abduction and external rotation
- nocturnal shoulder pain
- greater than 60 years of age
3 tests for supraspinatus tear
- CHampagne Toast
- Drop Arm Test
- Jobe’s or Empty Can
2 tests for infraspinatus and teres minor tears
- External rotation Lag Sign
- Horn Blowers
3 tests for subscapularis tears
- LIft Off test
- Bear Hug Test
- Belly Press
Describe the Champagne Toast test
test of supraspinatus tear
Position GH joint at 30deg abduction and flexion with slight ER, as if moving to perform a champagne toast. Apply resistance in this position
describe the Drop Arm Test (aka Codman’s test)
test of supraspinatus tear
Passively elevate pt’s shoulder to 90deg abduction and ak them to hold this position x10s. Postive test when client is unable to hold
Jobe’s/Empty Can Test
Test of supraspinatus tear
Pt holds arm out into 90deg of scaption and thumb pointed down into internal rotation. Apply resistance
Describe the External Rotation Lag Sign
special test for infraspinatus and teres minor tears
pt’s elbow flexion to 90deg and humerus held at 20deg elecation in scapular plane at maximal ER less 5deg to allow for elastic recoil
pt asked to hold this position. positive if pt cannot hold position actively. record magnitude of lag to nearest 5deg
Describe Horn Blower’s Test
test for infraspinatus an teres minor tears
flex pt’s elbow to 90 and shoulder in 90deg and place pt into 5deg less than full ER. Positive if they cannot hold this position
Describe the Lift Off Test
special test for subscapularis tear
place arm on dosum of the back and ask pt to internally rotate arm to lift hand off back. Pos test if pt unable to lift hand away from their back
Describe Bear Hug Test
special test for subscap tear
Place involved hand on opposite shoulder. Hold this position while therapist attempts to pull hand from shoulder using an ER force. Positive if pt cannot hold the position
describe the Belly Press test
special test for subscap tear
ask pt to push into their belly while keeping wrist straight. Positive test is wrist flexion and elbow dropping to side
supraspinatus action
abducts shoulder
infraspinatus and teres minor action
externally rotate shoulder
subscapularis action
internally rotates shoulder
what nerve innervates rhomboids?
dorsal scapular nerve, derived from C4 and C5 nerve roots
nerve most commonly injured in proximal humerus fx?
axillary
nerve most commonly injured in fx of middle third of the humeral shaft?
radial nerve
nerve that innervates latissimus dorsi?
thoracodorsal
nerve that innervates trapezius (upper fibers)?
accessory nerve
nerve that innervates coracobrachialis
musculocutaneous nerve
nerve that innervates subscapularis
subscapular nerve
nerve that innervates levator scapulae
dorsal scapular nerve
nerve that innervates subclavius
5th and 6th cervical nerves
what is the innervation and action of teres major?
adducts and interally rotates the shoulder. Innervated by lower subscapular nerve derviced from posterior cord of C5-C6
which muscles are horizontal abductors of the shoulder?
infraspinatus, posterior deltoid, and teres minor
what is the function and innervation of the coracobrachialis muscle?
flexion and adduction of glenohumeral joint
innervated by a branch from the lateral cord and the musculocutaneous nerve
originates on coracoid process and attaches to midportion of humerus
what is the function of the supraspinatus
abducts the shoulder and stabilizes humeral head in the GH joint during movement
what do infraspinatus and teres minor do?
externally rotate the humerus and stabilize humeral head during GH movement
what does teres major do?
internally rotates, adducts, and extends the shoulder
what does latissimus dorsi do?
internally rotates, adducts, and extends the shoulder
what are the four acromion shape types?
- flat (15% population)
- curved (43%)
- hooked (39%)
- convex/upturned (3%)
what is an arthrogram?
injecting a spinal needle into the shoulder joint under fluoroscope followed by injection of contrast medium to diagnose possible labral pathology
when treating RTC tendinitis/impingement, what main treatments should be performed?
strengthening the deltoid and scapulothoracic stabilizers while stretching pec minor
what are the scapular stabilizers?
serratus anterior, rhomboid major and minor, levator scapulae, and trapezius
what is a force couple?
2 forces of equal magnitude that work in opposite directs to produce rotation on a body
what are two force couples that move the shoulder?
- levator scap, upper trap, lower trap, and serratus anterior produce a smooth, rythmic motion to rotate and protract the scapula during UE elevation
- RTC and deltoid are a force couple of the GH joint
what is a SICK scapula?
Scapula Infera Coracoid Dyskinesis
A muscular overuse fatigue syndrome commonly seen in athletes with 3 major components:
1. scapula drops or is lower than other side
2. scapula is protracted
3. scapula displays increased abduction compared to other side
what clinical test can help differentiate between cervical pain from primary shoulder pain?
subacromial injection can differentiate between referred neural pain from cervical region. relief of pain with subacromial injection confirms shoulder pathology as the source of pain
what is the action of serratus anterior?
scapular abduction and upward/downward rotation of the scapula
what is the rotator interval?
anatomical space between the anterior border of the supraspinatus and the superior border of the subscapularis and reinforced by the coracoacromial ligament
what is a Hill-Sachs lesion?
impaction fracture of the posterosuperior humeral head
which exercises target periscapular strengthening and treatment of glenohumeral stability?
push-ups with a plus is the primary exercise
others include prone extension, horizontal abduction at 90deg with full external rotation, lawnmower, dynamic hug, and wall slide on forearms
all target serratus anterior and middle and lower trapezius muscles
In a GH arthroplasty, which is the only muscle transected and then repaired upon closure
subscapularis
what is the ideal GH angular position for shoiulder arthrodesis?
30deg abduction
30deg flexion
30deg internal rotation
in which direction does a shoulder typically dislocate after conventional TSA?
abduction and external rotation
in which direction does a shoulder typically dislocate after rTSA?
adduction with combined internal rotation and extension
this position allows the prosthesis to escape anteriorly and inferiorly
what is the capsular pattern for adhesive capsulitis?
both AROM and PROM are limited with PROM being restricted in the capsular pattern of external rotation being most limited followed by abduction and internal rotation
where do most adhesions occur in adhesive capsulitis?
In the anteroinferior portion of the capsule
this should be the focus of mobilization, modalities, and stretching
where does the subscapularis refer pain?
posterior deltoid, scapula, posterior arm, and wrist
where does infraspinatus refer pain?
anterior deltoid, shoulder joint, and medial border of the scapula, and to the front and lateral aspects of the arm and forearm
what RTC muscle is the main stabilizer of the scapula?
subscapularis
b/c of this, most sholder injuries involve subscapularis
subscap function affects scapular-humeral rhythm, thus causing abnormal shoulder mechanics during movement
what is the “terrible triad of the shoulder”?
rare combination of anterior shoulder dislocation, RTC tear, and neurologic injury
what is a “sail sign”?
radiograph finding which appears as a sail from a boat sign of effusion in the anterior fat pad of the elbow
in what position would you place your arm to isolate infraspinatus for palpation?
90 deg flexion, slight horizontal adduction, and external rotation
when is shoulder AROM typically initiated after a standard post-op medium sized RTC repair?
6 weeks
post-op rehab typically includes PROM, pain-control, pendulum, elbow ROM, and modalities x6 weeks
which cervical structures can refer pain to the shoulder?
discs, facets, nerve roots, intrinsic soft tissue (muscles, ligaments, joint capsules), and extrinsic musculature
cervical screenings such as ROM, spurling’s test, and cervical distraction test can help differentiate
what is the capsular pattern for the GH joint?
External rotation limited more than abduction; abduction limited more than internal rotation
A positive scapular flip sign occurs when the medial border of the scapula flips from the thoracic wall. This pathology can be an indicator of what type of palsy?
Spinal accessory nerve palsy
