Shoulder Flashcards
What kind of xray view do you use for AC jt and bony bankart fractures?
Westpoint-
- view
-patient must be prone, arm out to side hanging over table
-modified axial projection
-can see the anterior glenoid
Best Treatment for faster Return to play for mid shaft clavicle fractures
Open reduction and plate fixation
can return 10-12 weeks
What is a possible complication of clavicle injury and what are the signs?
Subclavian artery injury
-N/T in ipsilateral hand
-no motor weakness in UE’s
Which ligaments are primary restraints of posterrior and inferior instability
-Superior glenohumeral ligament
-Coracohumeral ligament have been shown to provide resistance to posterior and inferior instability. This occurs best in humeral ADD and ER
Which ligaments restrains anterior instability When shoulder at 45°,
the middle glenohumeral ligament
What happens in the shoulder joint ligaments When abduction increases to 90°,
the anterior band of the inferior glenohumeral ligament restrains against anterior instability
4 Types of SLAP TEARS
- Type 1: labral fraying
Type 2: biceps torn off- peel back
Type 3: bucket handle tear
Type 4: biceps split
Describe Type 2 SLAP tear
-detached biceps tendon
- during late cocking
- biceps tendon gets twisted and peels labrum and bicep from glenoid,
-can cause ant or post dislocation
Describe type 3 SLAP
Bucket handle tear
- labrum hangs into joint causing locking and popping
Describe Type 4 SLAP
-Bucket handle tear that SPLITS BICEPS TENDON
-can also cause locking and popping
The Lateral Scapular Slide Test (LSST)
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. Now, that being said, it isn’t a stellar test. Furthermore, the results suggest that sensitivity and specificity of the LSST measurements are poor and that the LSST should not be used to identify people with and without shoulder dysfunction.” However, you may still see it on your exam.
Secondary shoulder impingement
relative impingement occurring in the presence of rotator cuff weakness or instability of the capsule
describe injury to Suprascapular Nerve
innervates supraspinatus and infraspinatus, will see infraspintaus atrophy, can be compressed in the suprascapular notch or spinoglenoid notch
What is most commonly injuried nerve after shoulder dislocation
Axillary
-innervates deltoid, teres minor and long head of triceps
sensory distribution covers shoulder joint- regimental badge
What does a (-) negative LR of 0.92 show?
is weak and is not enough information to definitively rule out the condition.
a neg LR (-) of .92 is weak and is not enough information to definitively rule out the condition. -LR should be close to zero
Symptoms of anterior instability
-Feeling shoulder will dislocate when in throwing position
-Shoulder abducted and externally rotated
What percentage of dislocations reccur in less than 20 year olds?
Dislocation has been reported to recur in 66% to 100% of people aged 20 years or under
What percentage of shoulder dislocations occur in people aged between 20 and 40 years?
13% to 63%
Are you at large risk of shoulder dislocation if you are over 40?
No- 0-16%
What are signs of inferior instability:
paresthesia when carrying a heavy object at their side
symptoms of posterior instability
Symptoms when pushing a heavy door or performing pushups
Describe a Putti Platt surgery
Putti-Platt -will stabilize with a soft tissue restriction rather than a bony block allowing for less pain and degeneration,
This procedure divides the subscapularis tendon, overlaps it, and repositions it to achieve anterior capsular stability.
This is not performed in throwers due to the risk for range of motion loss. While this material was not covered in your weekly material, you will see a
Benefit of a bankart repair
Bankart repair can prevent anterior head translation during cocking phase of throwing
What happens to the shoulder during The cocking phase
– the torsional peel back force occurs on the biceps labral complex
-Accleration phase leads to more medial elbow injuries
Best treatment for traumatic anterior shoulder instability -dislocation
Surgery
Traumatic anterior shoulder instability rarely (<20%) can be successfully rehabilitated without surgery, there is a high incidence of recurrence.
A neuropraxia
- ‘class I’ or ‘transient’ or ‘delayed reversible’) type of nerve injury -usually only persists for several weeks.
-Weakness in shoulder ABD and ER
-decreased sensation over the lateral side of the proximal part of the arm. –The patient may have already recovered full neurological function at 4 weeks.
Axillary nerve injury is the most common nerve injury after anterior shoulder dislocation.
The Axillary nerve winds around the surgical neck of the humerus after passing to the posterior aspect of the arm through the quadrangular space. A traction injury can occur with a traumatic anterior dislocation. (about 30% experience mostly mild neuropraxic lesions with less than 5% experiencing significant damage.
Which of the following is commonly seen in collegiate and professional baseball pitchers after pitching for several innings?
Decreased passive IR of the throwing shoulder
The total arc of motion tends to decrease by ~10-11 degrees during a game, but increases throughout the season.
Quebec Decision Rule on sending for possible shoulder dislocation
1.. Aged 40 years or older AND humeral ecchymosis,
2. Aged 40 years or older AND first episode of dislocation, or
3. Younger than 40 years AND injury mechanism other than a fall from standing height or an atraumatic injury.
Average RTS after a type II SLAP lesion repair
12 months
What is a complication of SLAP repair?
suture anchor tips and their relative drilling site can lie very close to the suprascapular nerve and cause an iatrogenic injury
. If the patient experienced atrophy, she will have increased difficulty with scapular stabilization, especially overhead.
after SLAP repair and during rehab When progressing her into an interval hitting program, which serve or attack would you limit at first in an effort to prevent further injury
Jump Serve
Jump serves produce the most IR torque at the shoulder (40 N⋅m). The spike (either cross-body or straight ahead) is slightly less at 37 N⋅m. The float serve generates 31 N⋅m of torque. The roll shot produces only 16 N⋅m.
The running theory that contributes to an overhead athlete developing a SLAP lesion is
The peel-back mechanism describes a potential rationale for SLAP lesions in the throwing shoulder.
Burkhart et al. have hypothesized a peel-back mechanism that produces SLAP lesion in the overhead athlete. They suggest that when the shoulder is placed in a position of abduction and maximal external rotation, the rotation produces a twist at the base of the biceps, transmitting torsional force to the anchor.
Pradhan et al. (AJSM 2001) showed that the increased strain in the late cocking phase may contribute to the detachment of the labrum with the eccentric contraction of the biceps muscle that occurs with rapid extension of the elbow
Sprengel deformity
-relatively rare condition consisting of an elevated, dysplastic scapula that causes cosmetic deformity and restriction of shoulder range of motion
-Congenital elevation of the scapula is caused by an interruption in the normal caudal migration of the scapula.
-Because of the limited scapula motions and the new muscular attachments, AROM is severely limited.
-This congenital malformation probably occurs between the 9th and 12th weeks of gestation. Associated malformations are almost always present with a Sprengel deformity. These can include anomalies in the cervicothoracic vertebrae or the thoracic rib cage. The most common anomalies are absent or fused ribs, chest-wall asymmetry, Klippel-Feil Syndrome, cervical ribs, congenital scoliosis, and cervical spina bifida.
What is the best image for labral lesions?
Due to its superior diagnostic accuracy, MRA is the appropriate imaging modality for labral lesions.
Bankart Lesion
tear of anterior/inferior labrum
Bony Bankart
ant/inf labral tear and fracture of ant/inf glenoid fossa
Hill Sachs Lesion
fracture (cortical depression) of posterior head of humerus
Laterjet Procedure
1.transposition coracoid process to ant/inf glenoid fossa rim for greater congruency during ROM
2. conjoin tendons of shorthead of biceps brachii and coracobrachialis to subscapularis to create sling and reinforce anterior capsule
3. repair the anterior joint capsule unsing coracoid ligament
What organ can refer to the shoulder and what is the Sign called?
Spleen; Kehr’s sign
Pitching Risks in youth
3 x risk if pitch >100 innings per year
4 x if avg > 80 pitches/ game
5x if pitch > 8 months of the year
What does a slap repair entail?
SLAP repair a tear of the biceps tendon at the point where it connects to the labrum, a ring of cartilage that surrounds the shoulder socket
-drills a small hole into the glenoid bone where the labrum has torn away. A tiny anchor tied to a suture is implanted in the glenoid bone. Some tears may be repaired with just one anchor, others require multiple anchors.
- ties the sutures around the torn labrum, reattaching it firmly to the glenoid. If the tendon cannot be repaired, it is released.
During what phase of pitching do rhomboids have high level of EMG activity ?
Acceleration Phase
- so must have good scap retraction in throwers
How much force in shoulder during Late cocking/acceleration phase?
400 N shear force posteriorly
300 N shear force inferiorly
What happens in late cocking/acceleration phase of pitching?
- ant shear force of 400N thru shoulder
-Max ER ROM
-for the above- need contraction of RTC
-rapid IR in acceleration 7000dg/second
-valgus load to elbow- compression at lateral joint, shear at medial joint UCL
What happens in the deceleration phase of pitching?
-most violent phase
-400 N shear force posteriorly shoulder
-300 N shear force inferiorly shoulder
-Max contraction of RTC -most vulnerable
What are characteristics of Normal Throwers Shoulder?
generalized GHjt laxity
-61% pitchers and 47% fielders have + sulcus sign
Ideal isokinetc strength ratio ER/IR 65-75%
-Incr ER ROM- 118-141dgr pitchers, position players 108 dgr avg
-Decr IR ROM- pitchers ~ 62 degr
-Need total ARC Of Motion to be 180 and equal to other side
Acquired anterior instability
- different than Subacromial
-inc stress on anterior structures
-pinch of undersurface of RTC and ant/sup labrum at late cock/early acc
-Test with relocation test
suprascapular N
innervates:
-supraspinatus
-infraspinatus
-subscapularis
-teres major
comes from C4-6
axillary N
innervates deltoid and teres minor
What is a stinger?
sports-related injury of the brachial plexus
-a painful burning sensation that radiates from the neck down the arm - often accompanied by weakness or numbness of the affected area
-usually short term
What is fowler’s Sign
Jobe relocation test - tests for anterior instabiilty
What muscles dynamically resist excessive anterior shoulder translation?
Infraspinatus and teres minor
They actively resist anterior translation
What is the best intervention for pitcher who has severe winging 2/2 long thoracic napraxia?
Napraxia is short term
-Plank with end of range protractions
-elevated as necessary
napraxia
mild form of peripheral N injury
What is the rotator cuff interval composed of?
interactions of
-coracohumeral ligament
-superior glenohumeral ligament
-glenohumeral capsule
-supraspinatus tendon
-subscapularis tendon
How does a long thoracic palsy present?
- C5,6,7- (wings from heaven) serratus anterior
-medial border winging in pushup
-Decr Flexion strength and ROM
-6-9 months conservative RX
How does a suprascapular N palsy present?
- it is compression at suprascapular notch (most common) or spinoglenoid notch
-infraspinatus atrophy
-weak ER and ABD strength
-crossbody and IR is aggravating
-Test: SupraScapularNerve Test (SSN test)
-Rotate head away from shoulder and retract neck, positive if pain worsens
What is the SSN test?
Test for suprscapular N palsy
- SupraScapularNerve Test (SSN test)
-Rotate head away from shoulder and retract neck, positive if pain worsens
Quadrilateral Space Syndrome
-intermittent, poorly localized ant shoulder pain
-distally radiating parasthesias
-Aggs: flexion, ABD, ER
-Point tender over quad space- square btwn LH triceps, teres minor, teres major and surgical neck of humerus
Treatment: scapulae work and IR rotation stretching
Scapulothoracic Bursitis
@ major bursaw btwn serratus ant and chest wall and btwn suscap and serratus anterior
-pain localized to sup/med or inf angle during late cock/acc
-may have audible crepitus c active circumduction
Rx: Nsaids, possible cortisone inj, dec kyphosis, strengthen serr and subscap
Neurovascular Issues
TOS
Axillary N thrombosis
quadrilateral space syndrome
- all cause
-fatigue
-loss of velocity
-vague shoulder pain/heaviness/ache
-cramping in UE
Arterial Pathology
cold pale extremities
Venous compression
swelling, mottled discoloration
Vascular shoulder injuries
assess for bruits, thrills, dimunition in pulse
check capillary refill compared to non throwing arm
prn: xray for 1st rib, long transverse process C7 or bony abnormalities from clavicle frx
could also do MRI or US
TOS
subclavian artery and lower trunk of brachial plexus
-Fatigue in arm after activity. -Numbness or tingling in fingers
-Weakness of arm or neck.
-Throbbing lump near your collarbone.
Axillary Artery Thrombosis and Aneurysm
-Can be compressed by pectoralis majer- can predispose to thrombosis
- if vein compressed in costoclavicular pace with arm in ABD/ER- called “effort thrombosis”
RTC repair protocols
1-6 weeks: PROM: ER<20 scapular plane, Forward elevation <90
sling
6-7 weeks: PROM: ER<30 scapular plane, Forward elevation <120
AROM: elevation < 120
AFTER 3 MONTHS: Initiate RTC strengthening (with clearance from MD)
SLAP type 2 and 4 Repair Protocols
1st 6 weeks:
Sling
shoulder PROM only- ER < 45, F 120
No AROM of Elbow Flexion until 6 weeks
3 months Initiate resisted EF at 12 weeks
4 months:
RTS strengthening
Throwing program at 6 months
Anterior Stabilization Repair
Sling for 6 weeks
1-4 weeks PROM - 30 dgr
PROM restricted
8 weeks strengthening
Throw program at 4 months
what are the kinetic variables corrleated to injury in pitching?
inc elbow valgus torque
incr shoulder ER torque
with increased pitch velocity
What should knee flexion angle be a stride contact during pitching to avoid in shoulder force
between 38-50 dgrees
-stabilizes lead leg for trunk rotation
-allow force transfer from stride up thru chain
if too extended- lack of force transfer and more force in shoulder and elbow
If too flexed- dec effectiveness of throw
How does Bankart repair helps pitchers
prevents anterior head translation during cocking phase
What is the circle concept regarding joint injury?
forces leading to
damage due to impaction or compression on one
side of the joint may result in stretch or avulsion to
structures on the opposite of the joint
What is the difference between arthroscopic and open shoulder stabilization procedures?
the subscapularis is detached and reattached in open surgery
When does inferior pole of patella make contact with superior aspect of trochlea?
at 20 dgrs flexion
In what ROM is the patella contact area increased?
As knee flexes from 20-90 degrees of flexion
which exercises are best to balance Mid and lower traps with UT?
Sidelying ER,
sidelying forward flexion,
prone horizontal abduction with ER,
prone extension
What mm does your supra scapular nerve innervate?
infraspinatus
supraspinatus
from C5
Hyper-external glenohumeral rotation is thought to directly contribute to the following injury(ies) in throwers:
Anterior-inferior microinstability
Indirectly may contribute to SLAP tears, but typically secondary to increase anterior capsular laxity.
Muscle imbalances of the lumbo-pelvic-hip complex are thought to affect the shoulder girdle via the synergistic muscle groupings. Frontal plane pelvic-femoral stability is mediated by what
Gluteus medius, tensor fascia latae, abductor complex, and quadratus lumborum
What diagnosis causes isolated infraspinatus and supraspinatus muscle weakness. in overhead athletes, especially volleyball players
suprascapular notch entrapment
What is a shunt muscle?
A shunt muscle is described as one that originates close to the joint, and inserts far from the joint… a change in the muscle length will result in a small amount of distal bone motion. Shunt muscles function largely as stabilizer muscles.
pull along the bone
ex. long head of triceps
During a load and shift test, you note that the patient’s humeral head is felt to move over the glenoid rim, but returns back to the patient’s “normal” upon release. What grade of glenohumeral translation is given to this patient?
Grade II
Translation between 25 and 50% has been described as being a grade I positive test. Greater than 50% translation associated with a subsequent reduction of the humeral head is considered grade II, while the same amount of translation without reduction is recognized as grade III and the most serious type of a shift. There typically is not a grade IV.
Which of the following factors contributes to a greater likelihood for return-to-sports following articular cartilage repair in the knee?
Surgery within 12 months of the injury
younger age
size of defect
During the late cocking phase of overhead throwing which muscle(s) display the greatest amount of EMG activity?
suscapularis
During late-cocking, the abduction elevation remains relatively constant, possibly explaining the observed decreased activity of the deltoid and supraspinatus. The posterior rotator cuff muscles, the infraspinatus and the teres minor, are very active in producing external rotation of the humerus; and they contribute significantly to anterior glenohumeral stability by controlling anterior translation of the humeral head. However, the eccentric load of the subscapularis is greatest during the late cocking phase.
What is an u
What surgery is best for patient with 3 anterior shoulder dislocations and WITHOUT BONY INVOLVEMENT?
Bankart repair
In the absence of significant glenoid bone loss or Hill-Sachs deformity, arthoroscopic Bankart repair has been shown to result in reliable return to sport with acceptable recurrence rate.
What is different about the Putti platt procedure?
it is open surgery and found to have high long term risk of OA
describe types of biases
The example presented represents a confounding variable. If the results are different between the two techniques, it can be attributed to the fixation technique (a confounding variable), as opposed to the drilling technique of interest.
Selection bias would occur if the populations in each group were different.
Measurement bias is a general term for inaccurate measurement in any of the variables used in the study.
Detection bias is a form of measurement bias where one group has more frequent testing than the other.
Type II error is a statistical term for falsely stating that groups are not different when in reality there are differences. This typically occurs from a study with inadequate power.
A 32-year-old basketball player presents with a prominence of his scapular border. He has a history of ipsilateral neck surgery for lymph node biopsy and excision. On physical examination, there is lateral movement of the inferior border of the scapula with shoulder elevation. What is the innervation of the muscle most commonly associated with this pathology?
spinal accessory nerve-
-leads to trapezius weakness and lateral scapular winging
common following neck dissection sur- gery and can occur with blunt or penetrating trauma to the lateral neck region and cervical stretch injuries.
arcade of struthers
fibrous canal consisting of the medial head of the triceps brachii muscle and its aponeurotic expansion, which extended into the intermuscular septum
What are the sites for ulnar nerve compression in elbow/forearm?
The ulnar nerve is the most commonly affected nerve around the elbow. Potential sites of compression from proximal to distal include the medial intermuscular septum, arcade of Struthers, medial epicondyle, Osborne’s ligament, aponeurosis of the two heads of the flexor carpi ulnaris (arcuate ligament), and deep flexor/pronator aponeurosis.
Which type of SLAP tears would be MOST likely to require limitations on biceps activity following the procedure?
Type 2 and Type 4
Which of the following ligaments are the primary static restraints to inferior translation of the arm when the shoulder is in 0 degrees abduction and neutral rotation?
superiorglenoid lig
coracohumeral
they are taut in the resting position in order to prevent an inferior or anterior glide. The coracohumeral ligament is also taught with extremes of flexion, extension, or external rotation, and prevents an inferior glide.
Based on current evidence, assessment of baseball players with UCL tears SHOULD include:
Balance assessment
What is the difference between Bankart repair and SLAP repair?
Bankart is more for chronic instability, repairs labral tear with sutures and tightens the anterior capsule to secure joint
SLAP repair- for young overhead athletes, for symptomatic tears, - reattach the labrum and biceps tendon with sutures
Pitching LIMITS for 9-14 year olds
limited to 75 pitches per game,
600 pitches/season, and
2000-3000 pitches per year
Pitching LIMITS for 15-18
throw no more than
90 pitches per game and
pitch no more than 2 games per week.
Biceps subluxation/dislocations are associated with
pulley lesions and thus almost always accompanied
with
Subscapularis lesions
Durig The cockng phase – the torsional peel back force occurs on the biceps labral complex
Accleration phase leads to more medial elbow injuries
Rehabilitation following shoulder stabilization procedures will vary depending on whether the procedure was performed using an open or arthroscopic technique because: The subscapularis is detached and reattached during opoen surgery
What is commonly seen in collegiate and professional baseball pitchers after pitching for several innings
-Decreased passive internal rotation of the throwing shoulder
-The total arc of motion tends to decrease by ~10-11 degrees during a game, but increases throughout the season.
Which pitches create the most torque and force?
FASTBALL AND CURVEBALL
bc require more rotational movements
What is the pitching performance consequence of medial collateral ligament sprain/insufficiency?
throwing power loss but no pain or parasthesias
What degree deficit of total rotational ROM will put pitcher at greater risk for shoulder injury?
5 degrees
demonstrated that a deficit of greater than 5 degrees in total rotation motion (TRM) (shoulder external rotation + shoulder internal rotation) in professional baseball pitchers, led to a 2.5x increased risk of injury.
CPR for subacromial impingement
+infrapinatus MMT weakness
+ Hawkins Kennedy test
+ painful arc
What is The range of optimal ER:IR muscle strength in the overhead athlete
66% to 75%
Soreness rules
if have pain and pain continues during throwing:
stop and rest for 2 days, when return drop down 1 level
Sorness rules:
if soreness in warm up, goes away, then returns during workout
stop, 2 days rest, drop 1 level
Soreness Rules
Soreness Rules
soreness/symptoms NEXT day
Take 1 day rest, return at same level
Pitching mechanic faults
stride foot directed towards 1st base- this can reduce velocity 2/2 premature pelvic rotation
Typical Precautions - post op subscap repair
for 6 weeks
no passive ER >30-45 of ABD
no ER “stretching”
no active resisted IR
superior GHL prevents what?
inf humeral head subluxation
limits ER at 0 dgrs ABD
middle GHL limits what?
anterior translation at 45 dgrs ABD
Inferior GHL **
3 bands- posterior, inferior and anterior Bands
ANTERIOR BAND of INFERIOR LIG resists anterior translation at 90 dgrs ABD
O’Brien’s test
SLAP vs AC joint involvement
Biceps Load
SLAP
Crank TEst
test at 160dgr elevation
labral involvement
compression/rotation
labral lesion
lundington’s test
Biceps rupture
HOH pressing down with biceps- PT palpates for missing biceps tendon
xray view for Bankart and Hill Sach’s lesionss
West Point and Striker views
Zanca xray view used for?
AC joint
xray view for general shoulder injury
axillary
traumatic shoulder injury x ray views
axillary, Y view scapular, AP
Most common fracture in sports?
Clavicular fracture
RX for clavicular fracture
sling/swath
-immobilization for 6-8 weeks
- sometimes surgery
RX for scapular fracture
sling for 3 weeks
RX for humerus fracture
spint and immediate referral (shock is possible)
out of sports:
-shaft: ~3-4 months
-proximal ~2-6 months
Test Item cluster for RTC tear
+ drop arm
+painful arc
+ infraspinatus mm test
RTC (medium) repair Protocol
brace 6 weeks
week 1: PROM to 110
ER/IR in scap plane <30
PROM 6 weeks
Initiate AARM at 7 weeks, AROM once no shrug
Full AROM by 12-14 weeks
Week 16 low level ploys
18 weeks (4.5 months) begin light sports
6 months initiate return to sports program
Anterior stabilization SX protocol
Sling 6 weeks
restricted ABD and ER until 5 weeks
Full PROM and begin AROM 6 weeks
-light sport 3-4 month (golf, tennis, tennis serves at 4 month)
begin return to sport program- 4-5 months
SLAP 2 and 4 Repair Protocols
Sling 4 weeks
No resisted biceps for 12 weeks
6-9 months return to sport as appropriate (full return to pitching may be 12 months)
Bankart Repair Protocol
Sling 3-4 weeks,
AROM at 4-5 weeks
Full AROM by 10-12 weeks
Weeks 12+ begin plyos, sport specific ex
Months 5-9 return to sport accordingly
GH joint arthroplasty
PROM F, ABD, IR initially
AAROM at 2-4 weeks
NO ER ROM until 6-8 weeks
NO isometric IR 6-8 weeks
