Shoulder Flashcards
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Articulations at the shoulder joint
Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
Scapulothoracic, not a true joint but works with AC and SC
What type of joint is the sternoclavicular, acromioclavicular and glenohumeral joint.
SC and AC - synovial plane
GH - synovial ball and socket
Bones involved with the sternoclavicular joint
Manubrium of sternum and clavicle
Bones involved with the acromioclavicular joint
Acromium process of scapula and lateral end clavicle
Bones involved with the glenohumeral joint
Scapula (glenoid fossa) and humerus
Type of cartilage and membrane in the joint
Hyaline cartilage and synovial membrane
what is it attached to?
Describe the shoulder capsule
Attached to labrum and glenoid rim to articular margins of humerus
Except inferiorly where extends 1-2cm onto the neck (lax inferiorly- mobility).
Reinforced by rotator cuff and biceps long head.
Additional features in the shoulder joint
Sternoclavicular joint - Fibrocartilage disk for congruency, shock absorption
Acromioclavicular disc- Unknown
Glenohumeral join- Bursae, Labrum- congruency
Movements at the shoulder joint
Abduction
Adduction
Flexion
Extension
Internal rotation
External rotation
3 muscles
Rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor and subscapularis
5 muscles
Muscles that make up the shoulder girdle
Pec major
Pec minor
Deltoids
Trapezius
Serratus anterior
4 muscles
Shoulder flexors
Anterior deltoid
Coracobrachialis
Pec major
Weakly - Biceps brachii
3 muscles
Shoulder extension muscles
Posterior deltoid
Latissimus dorsi
Teres major
5 muscles
Internal rotators
Subscapularis
Pec major
Latissimus dorsi
Teres major
Anterior aspect of deltoid
2 muscles
External rotators
Infraspinatus
Teres minor
3 muscles
Adduction
Pec major
Latissimus dorsi
Teres major
4 muscles - 3 points of degrees
Abduction
Supraspinatus - 0-15
Middle fibres of deltoid - 15-90
Trap and serratus anterior beyond 90 degrees
Ligament pathology
AC joint sprain
Disruption of the middle and inferior GH ligaments
Blood and nerve supply pathology
Referral from neck - cervical radiculopathy
Muscle shoulder pathology
GH stability
Rotator cuff pathology/subacromial shoulder pain
Includes rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis.
Articulations pathology
Atraumatic - dislocation *GH
Traumatic - GH, AC joint
Bone pathology
Fractures- clavicle, humerus
Hyaline cartilage pathology-
OA-
AC joint
GH joint
Capsule pathology
RA - GH joint
Synovial membrane pathology
Adhesive capsulitis/ frozen shoulder
Additional features pathology
Damage to glenoid labrum
Superior Labral tear from ant. To post. (SLAP)
Bankart – damage to inferior, anterior labrum.
=ongoing instability
Rotator cuff pathology/ subacromial shoulder pain
Includes rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis
Diagnostic categories
1) Those that need onward referral
2) Referred from the neck
3) Traumatic injuries- fractures, dislocations and AC joint sprain
4) Atraumatic pathology - Instability, Acromioclavicular joint disease, Glenohumeral joint disease – Frozen shoulder, Arthritis and Rotator Cuff Tendinopathy
Common age of shoulder instability
10-36
Common age of AC joint disease
> 30 years
Common age of glenohumeral joint issues (frozen shoulder, arthritis)
35-65
Common age for rotator cuff tendinopathy
35-75 years
People that need onward referral
Malignancy-
Weight loss, night pain, night sweats and fever
Acute rotator cuff-
Trauma, pain and weakness
Septic arthritis -
fever or systemically unwell, red skin, hot, painful joint
Unreduced dislocation -
Loss movement, trauma leading to loss of rotation and abnormal shape
Inflammatory arthritis-
Swelling, early morning stiffness, FH RA, swollen joint +- heat
Neurological lesion-
Gait disturbances, unexplained muscle wasting and weakness, sensory loss
UMN - babinski and clonus
LMN - reflexes, dermatomes and myotomes
What is it and what is the most common cause
Cervical radiculopathy
Pain in one or both upper extremities which corresponds to the dermatome of the involved cervical nerve root.
Most common cause degenerative change: disc herniation, spondylosis (spinal OA) causing bony hypertrophy of facet joints.
Symptoms reproduced with what types of movement
Urgent referral if…
Cervical radiculopathy- objective
Symptoms reproduced with Neck active and passive ROM. +/- Changes in Dermatomes, Myotomes and reflexes.
Urgent referral if severe or progressive motor weakness or severe or progressive sensory loss
If 4-6 weeks or more or neurological signs refer to confirm diagnosis (medical Rx)
<4-6 weeks and no objective neurological signs = conservative management
Cervical radiculopathy
Subjective
pins and needles, numbness, weakness, aggravating and easing linked to neck, symptoms may go down the arm
Cervical radiculopathy-
treatment
Reassurance that prognosis is good in most cases.
Most will improve regardless of treatment.
88% will improve within four weeks with non-operative treatment (Childress and Becker 2016)
Encourage activity and return to normal lifestyle (inc work). If neck restricted not to drive. No collars.
Clavicle fracture subjective
Localised pain.
Pain and function reflective of stage of healing.
Clavicle fracture objective
Obs: protracted shoulder girdle position
Difficulty with active Protraction, Retraction, elevation and depression and active and passive GH flexion and abduction through elevation.
Clavicle fracture treatment
Common shoulder fractures (child>adult)
Sling 2-6 weeks of immobilisation
Reassurance- good outcome in >90% cases of minimally displaced or not displaced at 24 weeks (Robinson et al 2004)
Sometimes will need physio for AROM, stretches, strengthening with an aim to return function.
closed pack positon
Clavicle fracture
Sternoclavicular joint
(synovial plane = gliding)
Close packed position: Maximum shoulder elevation.
What movements
Clavicle fracture
Acromioclavicular joint
(synovial plane = gliding)
During Abduction and flexion the clavicle rotates about its long axis posteriorly. If unable, the movement of the scapula is affected which affects GH joint flex and Ab.
AC joint sprain
Ligaments involved and role of the AC joint
Coracoclavicular ligament
Acromioclavicular ligament
Coracoacromial ligament
Role of AC joint:
Allows overhead and across the body movement
Transmits force from arm to rest of body during activities such as pushing, pulling and lifting
Subjective AC joint sprain
Localised pain over AC joint, aggravated by heavy lifting, over head and across the body movements.
Observation,palpation, movements
AC joint sprain objective
Obs- swelling, bruising, hard lump may be present at top of shoulder.
Palpation: specific tenderness over AC joint
Difficulty with GH flexion through elevation and horizontal adduction (Cross body test)
AC joint sprain treatment
Ligament healing times: 6-8 weeks, in this time protect from over stretching (may use sling)
Physio: normalise joint ROM, muscle lengths, proprioception, minimise your chance of re-injury (return to work or sport 8-12 weeks)
Grade sprain
MILD: Grade I (intact joint minor tear of acromioclavicular ligaments)
Grade II (up to 50% and stretching of ligaments)
SEVERE: Grade III (>50% vertical subluxation)= Orthopaedic opinion
Fall-arm position
Traumatic dislocation- how does it happen?
Arm outstretched in an externally rotated and abducted position
Most common direction of dislocation
Anterior
Traumatic GH disclocation
Restrictions
Anterior dislocations assess with…
Restrictions:
Concave glenoid,
labrum,
capsule,
superior, middle and inferior GH ligament
long head of biceps
rotator cuff.
Damage to labrum and middle and inferior GH ligaments
Rotator Cuff tears
Gr tuberosity fracture
Traumatic Gh joint disclocation
Orthopaedic instruction.
Obs: position of joint, posture
AROM as comfortable
Traumatic Gh joint dislocation
Subjective
Mechanism, relocation -time, who, where, pre-existing sh instability? Next clinic appointment.
Traumatic Gh joint dislocation - treatment
A&E and fracture clinic. Orthopaedic management and review.
Following assessment and reduction:
*Early mobilization as pain allows, course of physiotherapy usually 4-12 weeks.
*Urgent Ortho opinion if pain and weakness 2-3 weeks post dislocation, suspect rotator cuff tear.
Prognosis of 1st traumatic dislocation
At 1-year - recurrent instability rate was 39% (Olds et al. 2015), 55.7% within first two years and 66.8% by the fifth year
Risk factors with disclocation and recurrent instability
<40 years olf - 13 x
men - 3 x
Gretaer tuberosity fracture- 7 x
Hyperlaxity - 3 x
What two things cause this instability?
Atraumatic instability
GH joint Synovial ball and socket with 3 degrees of freedom
Mobility; the shoulder joint is capable of large complex movements in all anatomical planes.
Stability; because of the lack of congruency stability is largely dependent on muscles, capsule and ligaments.
Increased mobility + decreased stability = imbalance
Atraumatic instability- objective
Performing functional movements that reproduce symptoms. Often instability tests are not required.
Normally full active range of motion, Proprioception
Muscle power: isometric test rotator cuff in different positions. Ax whole kinetic chain e.g. squat, SLS, bridge
Atraumatic instability- subjective
Onset (gradual vs sudden), “falls out” versus “pulled out”. Doesn’t feel right, not is place. Feels like it needs to click.
PMH: Connective tissue Disorders (EDS, Marfans), hypermobility
Atraumatic instability treatment-
Conservative rehabilitation program.
Rotator cuff strengthening, proprioception, building speed and using the whole kinetic chain.
Psychological aspect-to address any contributing factors, regain confidence and reduce fear.
Improve general activity
Prognosis: Aim to return to activity and function
Frozen shoulder
A painful contracture of the GH joint capsule which leads to stiffness and disability.
3 phases 1) Painful 2-9 months 2) Stiffness 4-12 months 3) Resolution 12-42 months
Recently classified as pain predominant and stiffness predominant
Frozen shoulder-
Objective
Reduced AROM and PROM
Capsular pattern - limited Ex rot
Reduced Accessory movements: convex humeral head glides in opposite direction to angular movement of bone.
Frozen shoulder subjective
Idiopathic (gradual onset) or secondary to trauma.
Pain in deltoid region with worsening stiffness.
Difficulty doing up bra strap, putting on deodorant, putting on coat, changing gear in car
Frozen shoulder treatment-
Symptoms settle in 18-24 months.
Analgesia–Paracetamol, NSAIDS, corticosteroid inj.
Physiotherapy for 6/52 then RV and either refer to secondary care or cont for 6/52.
To continue to use the arm when painful to maintain ROM, manual therapy, stretches, hydrotherapy, heat
OA objective
Painful high arc on AROM
Positive cross body arm test.
Tender on palpation of AC joint
OA subjective
Difficulty with activities above the head, washing hair, putting out washing.
Risk factors are those that do over-head work: painters, plasters, weight-lifters.
> 60 years for OA
20-50 years for injuries to AC joint.
Treatment of OA- joint disease
Activity modification (avoiding cross over and heavy lifting), analgesia, referral to physio.
Physio- management of symptoms
Subacromial shoulder pain
rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis
Rotator cuff disorders- objective
Painful arc of Abduction (in scapula plane). Pain between 70-120 degrees
-Pain worse if thumb down and against resistance.
*Isometric muscle testing – belly press +/- lift off sign for subscapularis
*Special tests- Hawkins and Kennedy and Neer.
Rotator cuff disorders subjective
Can describe: “catches me out”, pain on lifting e.g. kettle, or activities with arm above head.
May describe a painful arc.
**Onset: **May occur gradually or after a change in activity/loading – sport, occupation, recent life change (moved house) or training
Sleep: May have night pain due to difficulty laying on shoulder
Subscapularis - O and I
Origin: Entire under surface of the scapula (subscapular fossea).
Insertion: Less tubercle of the humerus.
Latissimus dorsi - O and I
Origin – Posterior crest of the ilium (via the Thoracolumbar fascia).
Posterior sacrum.
Spinous processes of T7-L5.
Insertion – Intertubercular groove (between the greater and lesser tuberosities) of the humerus.
Infraspinatus - O and I
Origin – Posterior surface of the scapula (below the spine of the scapula).
Insertion – Greater tuberosity on the humerus
Teres minor O and I
Origin: Midsection of the lateral border of the scapula.
Insertion: Greater tuberosity on the humerus.
Teres major O and I
Origin: Lower 1/3 of the lateral border of the scapula.
Insertion: Intertubercular goove (between the greater and lesser tubercles) of the humerus
Supraspinatus O and I
Origin: Supraspinous fossa.
Insertion: Greater tuberosity of the humerus.
Deltoid O and I
Origin –Outer 1/3 of the clavicle
Acromion process
Spine of the scapula
Insertion –Deltoid tuberosity on the humerus
People that need onward referral
Malignancy
S) h/o cancer, weight loss, night pain, night sweats and fever O) Mass or swelling
Acute rotator cuff tear
S) Trauma, pain and weakness O) sudden inability to raise arm (with or without trauma)
Septic arthritis.
S) fever or systemically unwell O) Red skin, hot, painful joint
- Unreduced dislocation
S) Loss Movement O) Trauma leading to loss of rotation and abnormal shape - Inflammatory arthritis
S) Swelling, Early Morning Stiffness (EMS), FH RA, O) Swollen joint +/- heat - Neurological lesion
S) Gait disturbance and O) Unexplained muscle wasting and weakness, sensory loss
UMN- Babinski and clonus
LMN- reflexes, dermatomes and myotomes.
