SHOULDER Flashcards

1
Q

SHOULDER - ROM

A
  • Flexion - 180
  • Extension - 60
  • Internal rotation - 90
  • External rotation - 80
  • Abduction - 180
  • Adduction - 35
  • Scapulohumeral (humerus : scapula) - 120 : 60
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2
Q

SHOULDER - MYOTOMES

A
  • Shoulder elevation - C4, XI
  • Deltoid - C5, C6 - axillary
  • Brachioradialis - C5, C6 - radial
  • Biceps - C5, C6 - musculocutaneous
  • Triceps - C6, C7, C8, T1 - radial
  • Wrist extensors - C6, C7, C8 - radial
  • Wrist flexors - C6, C7 - median/ulnar
  • Finger flexors - C7, C8, T1 - ulnar/median
  • Interossei - C7, C8, T1 - ulnar
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3
Q

SHOULDER ORTHO TESTS - SCREENING

A

SCREENING - Drop arm

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4
Q

SHOULDER ORTHO TESTS - IMPINGEMENT

A

IMPINGEMENT - Hawkins-Kennedy, Painful arc

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5
Q

SHOULDER ORTHO TESTS - BICEPS TENDINITIS

A

BICEPS TENDINITIS - Speeds, Yergasons

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6
Q

SHOULDER ORTHO TESTS - ROTATOR CUFF

A

ROTATOR CUFF - Empty can

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7
Q

SHOULDER ORTHO TESTS - LABRAL TEAR

A

LABRAL TEAR - Clunk, Crank, Obrien’s

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8
Q

SHOULDER ORTHO TESTS - GH JOINT INSTABILITY

A

GLENOHUMERAL JOINT INSTABILITY - Anterior/posterior drawer

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9
Q

SHOULDER - JOINT TYPE

A
  • Ball & socket - glenohumeral
  • Gliding - scapulothoracic
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10
Q

SHOULDER - ARTICULAR SURFACES

A
  • Glenohumeral - convex (head of humerus) on concave (glenoid fossa)
  • Scapulothoracic - concave (subscapular fossa) on convex (posterior ribs)
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11
Q

SHOULDER - MAIN MUSCLE ACTIONS - FLEXION

A
  • FLEXION - anterior deltoid, biceps brachii, coracobrachialis, pectoralis major
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12
Q

SHOULDER - MAIN MUSCLE ACTIONS - EXTENSION

A
  • EXTENSION - posterior deltoid, latissimus dorsi, triceps brachii, teres major
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13
Q

SHOULDER - MAIN MUSCLE ACTIONS - ABDUCTION

A
  • ABDUCTION - middle deltoid, supraspinatus
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14
Q

SHOULDER - MAIN MUSCLE ACTIONS - ADDUCTION

A
  • ADDUCTION - latissimus dorsi, teres major, pectoralis major
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15
Q

SHOULDER - MAIN MUSCLE ACTIONS - HORIZONTAL ADDUCTION

A
  • HORIZONTAL ADDUCTION - pectoralis major, coracobrachialis, anterior deltoid
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16
Q

SHOULDER - MAIN MUSCLE ACTIONS - HORIZONTAL ABDUCTION

A
  • HORIZONTAL ABDUCTION - posterior deltoid, teres major
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17
Q

SHOULDER - MAIN MUSCLE ACTIONS - INTERNAL ROTATION

A
  • INTERNAL ROTATION - subscapularis, pectoralis major, latissimus dorsi
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18
Q

SHOULDER - MAIN MUSCLE ACTIONS - EXTERNAL ROTATION

A
  • EXTERNAL ROTATION - infraspinatus, teres minor
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19
Q

SHOULDER - RESTING POSITION

A

GH: abduction - 55-70 horizontal adduction - 30

Acromioclavicular: arm at side

Sternoclavicular: arm at side

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20
Q

SHOULDER - CLOSED PACKED POSITION

A

GH: maximal abduction & lateral rotation

Acromioclavicular: abduction - 90

Sternoclavicular: full elevation

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21
Q

SHOULDER - NORMAL END FEEL

A

FLEXION - elastic, firm-bony contact

EXTENSION - firm

ABDUCTION - elastic

INTERNAL/EXTERNAL ROTATION - elastic/firm

HORIZONTAL ADDUCTION - soft tissue

HORIZONTAL ABDUCTION - firm/elastic

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22
Q

SHOULDER - ABNORMAL END FEEL

A

Empty - Subacromial bursitis

Hard capsular - Frozen shoulder

Late myospasm - Instability

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23
Q

SHOULDER - CONDITIONS - AC SEPERATION

A

Hx - prior trauma - fall onto shoulder or impact over shoulder
S&S - possible step defect; tenderness to palpation over AC joint; +ve Obrien’s
DDx - supraspinatus rupture, impingement syndrome, rotator cuff tear

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24
Q

SHOULDER - CONDITIONS - ADHESIVE CAPSULITIS

A

Hx - Pt age 40-60, usually female, weeks of shoulder pain and restriction
S&S - restricted AROM in clear capsular pattern (external rotation > abduction > internal rotation); extermally painful & limited PROM
DDx - cervical pathology, impingement syndrome, rotator cuff tear

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25
SHOULDER - CONDITIONS - BICIPITAL TENDONITIS
Hx - pain over anterior shoulder, history of repetitive elbow flexion (weight lifter) S&S - pain with direct palpation of biceps long head tendon; pain with resisted horizontal adduction DDx - cervical pathology, rotator cuff strain
26
SHOULDER - CONDITIONS - SUBACROMIAL BURSITIS
Hx - pain over superior or lateral GH joint, pain at night, difficulty sleeping S&S - tender palpation over acromion/deltoid; decreased shoulder ROM in abduction & flexion; pain may be relieved by GH inferior distraction DDx - cervical pathology, ortator cuff strain, impingement syndrome
27
SHOULDER - CONDITIONS - GH OSTEOARTHRITIS
Hx - insidious onset of pain, morning stiffness, worse with excessive activity S&S - crepitus and pain with ROM; +ve Ellman compression test DDx - AC OA, GH instability, impingement syndrome
28
SHOULDER - CONDITIONS - IMPINGEMENT
Hx - pain with overhead movements, may refer pain down lateral arm S&S - pain with ROM; +ve painful arc , Hawkins-Kennedy, Neer’s DDx - cervical pathology, GH instability, poor posture
29
SHOULDER - CONDITIONS - INSTABILITY
Hx - prior trauma; patient may have increased motion; patient may have impingement type symptoms due to excess GH movement S&S - observation of sulcus sign; +ve load and shift test DDx - rotator cuff strain, impingement syndrome, congenital ligament laxity
30
SHOULDER CONDITIONS - ROTATOR CUFF TEAR
Hx - prior trauma - lifting or throwing injury; degeneration of rotator cuff? (elderly) S&S - weakness in specific rotator cuff movements; abnormal scapulohumeral rhythm; +ve drop arm test, painful arc, impingement DDx - supraspinatus rupture, impingement syndrome, congenital ligament laxity
31
SHOULDER - CONDITIONS - SUPRASPINATUS TENDONITIS
Hx - pain with overhead movements or hand placed behind back S&S - exquisite pain with resisted supraspinatus movements; pain with direct palpation; +ve empty can test, impingement DDx - cervical pathology, GH instability, complete supraspinatus rupture
32
SHOULDER - CONDITIONS - TOS
Hx - pain and paresthesia, possible muscle weakness into shoulder, arm and/or hand S&S - my-spasm of cervical musculature (depending on cause); +ve TOS tests DDx - cervical radiculopathy, cervical disc herniation, carpal tunnel syndrome
33
SHOULDER - ORTHO TEST - APPREHENSION TEST
- Pt seated or supine - Shoulder abducted 90, elbow flexed 90 - Examiner gently applies P-A pressure over the humerus - Observe pt for signs of apprehension or discomfort
34
SHOULDER - ORTHO TEST - APPREHENSION TEST - POSITIVE
**Anterior GH instability** - Excessive anterior translation - Dislocation - Pt apprehension
35
SHOULDER - ORTHO TEST - APPREHENSION TEST - SN & SP
**SN**: 53 **SP**: 99
36
SHOULDER - ORTHO TEST - CLUNK
- Pt seated or supine - Shoulder abducted 150 - Examiner rotates humerus externally and applies anterior pressure on the humeral head
37
SHOULDER - ORTHO TEST - CLUNK - POSITIVE
**Glenoid labral lesion, Anterior instability** - Shoulder pain - Crepitus
38
SHOULDER - ORTHO TEST - CLUNK - SN & SP
**SN**: 44 **SP**: 68
39
SHOULDER - ORTHO TEST - CRANK
- Pt seated or supine - Shoulder abducted 180 and elbow flexed 90 - Examiner applies long axis compression and rotates humerus internally and externally
40
SHOULDER - ORTHO TEST - CRANK - POSITIVE
**Glenoid labral lesion** - Shoulder pain - Crepitus
41
SHOULDER - ORTHO TEST - CRANK - SN & SP
**SN**: 46-91 **SP:** 93
42
SHOULDER - ORTHO TEST - DROP ARM TEST
- Pt seated - Examiner passively abducts shoulders to 90 with solid support - Examiner suddenly lets go and asks pt to catch themselves
43
SHOULDER - ORTHO TEST - DROP ARM TEST - POSITIVE
**Painful arc syndrome, Bursitis, Rotator cuff strain or tear, tendinitis/impingement** - Pain/weakness - Racheting movement **Severe injury (grade 3 cuff strain)** - Unable to catch herself
44
SHOULDER - ORTHO TEST - DROP ARM TEST - SN & SP
**SN:** 8-27 **SP:** 88-100
45
SHOULDER - ORTHO TEST - EMPTY CAN
- Pt standing or seated - Pt actively raises straight arm (palm up) to 120 in scapular plane - At apex pt internally rotates arm (thumb down) - Pt then lowers straight arm internally rotated slowly to the body
46
SHOULDER - ORTHO TEST - EMPTY CAN - POSITIVE
**Injury or lesion of supraspinatus muscle** - Pain or weakness
47
SHOULDER - ORTHO TEST - EMPTY CAN - SN & SP
**SN**: 44-89 **SP**: 50-90
48
SHOULDER - ORTHO TEST - FULL CAN
- Pt seated - Pt actively raises straight arm (palm up) to 120 in scapula plane - At apex examiner applies downward pressure and notes pt strength
49
SHOULDER - ORTHO TEST - FULL CAN - POSITIVE
**Injury or lesion of supraspinatus muscle** - Pain or weakness
50
SHOULDER - ORTHO TEST - FULL CAN - SN & SP
**SN**: 86 **SP**: 57
51
SHOULDER - ORTHO TEST - HAWKINS-KENNEDY
- Pt seated - Shoulder abducted 90, elbow flexed 90 - Examiner internally rotates and horizontally adducts shoulder to pinch greater tuberosity of humerus against acromion
52
SHOULDER - ORTHO TEST - HAWKINS-KENNEDY - POSITIVE
**Supraspinatus impingement** - Pain in anterolateral shoulder
53
SHOULDER - ORTHO TEST - HAWKINS-KENNEDY - SN & SP
**SN**: 50-100 **SP**: 44-76
54
SHOULDER - ORTHO TEST - KIM TEST - POSITIVE
**Posterior glenoid labrum pathology** - Pain in posterior shoulder
55
SHOULDER - ORTHO TEST - KIM TEST
- Pt seated with back supported - Examiner stabilises pt elbow and middle humerus - Examiner flexes pt shoulder in the scapular plane - As shoulder flexion occurs examiner applies long axis compression to induce posterior-inferior glide of the humerus
56
SHOULDER - ORTHO TEST - KIM TEST - SN & SP
**SN**: 80 **SP**: 94
57
SHOULDER - ORTHO TEST - APPREHENSION-RELOCATION TEST
- Pt supine - Shoulder abducted 120 and elbow flexed 90 - Examiner externally rotates pt shoulder and applies a posterior force over the anterior humeral head - Examiner observes pt for pain or apprehension
58
SHOULDER - ORTHO TEST - APPREHENSION-RELOCATION TEST - POSITIVE
**Posterior glenohumeral instability** - Apprehension - Increased motion **Anterior instability** - No apprehension - Decreased pain
59
SHOULDER - ORTHO TEST - APPREHENSION-RELOCATION TEST - SN & SP
**SN**: 92 **SP**: 100
60
SHOULDER - ORTHO TEST - NEER'S TEST
- Pt seated with arms in dependant position - Examiner first raises pt’s straight arm through full range of flexion (passively) with arm externally rotated (palm up) - Repeat with arm internally rotated (palm down)
61
SHOULDER - ORTHO TEST - NEER'S TEST - POSITIVE
**Supraspinatus impingement, subacromial bursitis** - Pain with internally rotated shoulder **Biceps long-head impingement** - Pain with externally rotated shoulder
62
SHOULDER - ORTHO TEST - NEER'S TEST - SN & SP
**SN**: 0-89 **SP**: 48-100
63
SHOULDER - ORTHO TEST - OBRIEN'S TEST
- Pt seated - Shoulder flexed to 90 and arm adducted 10-20 - Internally rotate pt arm (thumb down) - Examiner pushes down on the arm while pt attempts to maintain position - Externally rotate pt arm (palm up)
64
SHOULDER - ORTHO TEST - OBRIEN'S TEST - POSITIVE
- Pt seated - Shoulder flexed to 90 and arm adducted 10-20 - Internally rotate pt arm (thumb down) - Examiner pushes down on the arm while pt attempts to maintain position - Externally rotate pt arm (palm up)
65
SHOULDER - ORTHO TEST - OBRIEN'S TEST - SN & SP
**SN**: 16-88 **SP**: 13-90
66
SHOULDER - ORTHO TEST - PAINFUL ARC
- Pt standing or seated - Examiner asks pt to abduct shoulders - Observe for signs of discomfort or pain
67
SHOULDER - ORTHO TEST - PAINFUL ARC - POSITIVE
**Rotator cuff, AC pathology, Impingement syndrome** - Shoulder pain
68
SHOULDER - ORTHO TEST - PAINFUL ARC - SN & SP
**SN**: 33-98 **SP**: 10-81
69
SHOULDER - ORTHO TEST - RELOCATION TEST
- Pt supine - After attempting the anterior apprehension test the examiner applys anterior to posterior pressure over the GH joint
70
SHOULDER - ORTHO TEST - RELOCATION TEST - POSITIVE
**GH instability, anterior glenoid labrum tear** - Decreased in pain or apprehension
71
SHOULDER - ORTHO TEST - SPEED'S TEST
- Pt seated - Forearm extended and supinated with arm at pt side - Pt actively flexes arm to 120 - Examiner applies resistance to this motion while palpating the bicipital groove
72
SHOULDER - ORTHO TEST - SPEED'S TEST - POSITIVE
**Bicipital tendinitis, impingement syndrome, labral lesion or bursitis** - Pain
73
SHOULDER - ORTHO TEST - SPEED'S TEST - SN & SP
**SN**: 4-100 **SP**: 11-100
74
SHOULDER - ORTHO TEST - YERGASON'S TEST
- Pt seated - Elbow flexed 90, forearm pronated - Examiner grips forearm and palpates biceps long head tendon - Pt actively flexes and supinates forearm and externally rotates arm - Examiner resists patient motion
75
SHOULDER - ORTHO TEST - YERGASON'S TEST - POSITIVE
**Tendonitis or strain** - Pain over bicipital groove **Glenoid labrum pathology** - Pain in shoulder **Torn transverse humeral ligament (bicipital instability)** - Tendon slipping out of groove
76
SHOULDER - ORTHO TEST - YERGASON'S TEST - SN & SP
**SN**: 9-50 **SP**: 79-93
77
SHOULDER - ORTHO TEST - MODIFIED YERGASON'S TEST
- Pt seated - Pt abducts shoulder to 90, externally rotates arm and supinates forearm - Examiner applies resistance to motion and palpates bicipital groove
78
SHOULDER - ORTHO TEST - MODIFIED YERGASON'S TEST - POSITIVE
**Torn transverse humeral ligament** - Pain or tendon slipping out of the groove
79
SHOULDER - TENDINITIS/BURSITIS/SUBACROMIAL IMPINGEMENT
- Subacromial impingement is also known as rotator cuff tendinitis or bursitis - Occurs when the rotator cuff becomes irritated underneath the acromion
80
SHOULDER - TENDINITIS/BURSITIS/SUBACROMIAL IMPINGEMENT - RISK FACTORS
- Sports - Occupational risks - Overhead motions
81
SHOULDER - TENDINITIS/BURSITIS/SUBACROMIAL IMPINGEMENT - POPULATION AFFECTED
- Over 40 - Can be younger but there is often an underlying problem in this case
82
SHOULDER - TENDINITIS/BURSITIS/SUBACROMIAL IMPINGEMENT - CLINICAL PRESENTATION
- Most symptoms of impingement begin gradually and have a chronic component that progresses over several months - Pt likely presents with - Recent history of overactivity or Onset of moderate to occasionally severe pain with AROM of the shoulder - Pt often complains of pain on the top and front of the shoulder - Symptoms also include - Localised tenderness - Inflammation - Edema - Loss of function - Weakness and stiffness of the shoulder may also occur, but this is usually secondary to pain and not muscle weakness
83
SHOULDER - TENDINITIS/BURSITIS/SUBACROMIAL IMPINGEMENT - PROGNOSIS
- Most pt with impingement syndrome or small rotator cuff tearing will recover within 6 months - Supervised physical therapy and NSAIDs are valuable - In time symptoms will gradually subside
84
SHOULDER - CALCIFIC TENDINITIS
- Calcium hydroxyapatite crystals are deposited in the supraspinatus tendon
85
SHOULDER - CALCIFIC TENDINITIS - RISK FACTORS
- Aging - Damage to the tendons - A lack of oxygen to the tendons - Genetics - Abnormal thyroid gland activity - Cells growing abnormally - Chemicals produced by the body to fight inflammation - Metabolic diseases - Diabetes
86
SHOULDER - CALCIFIC TENDINITIS - POPULATION AFFECTED
**Acute** - 30 – 50-year-olds
87
SHOULDER - CALCIFIC TENDINITIS - CLINICAL PRESENTATION - ACUTE
- Aching, sometimes following overuse develops and increases in severity within hours - After a few days pain subsides, and the shoulder gradually returns to normal - In some pt the process is less dramatic and recovery slower - During the acute stage the arm is held immobile as the joint is usually too tender to permit palpation or movement - Pain may be intense during the acute phase and can be confused with acute infection
88
SHOULDER - CALCIFIC TENDINITIS - CLINICAL PRESENTATION - CHRONIC
- Asymptomatic calcification of the rotator cuff is common - Often is only found as an incidental finding in shoulder x-rays - Can be seen in association with impingement syndrome
89
SHOULDER - CALCIFIC TENDINITIS - PROGNOSIS
**Acute** - If symptoms are not severe and the arm is rested in a sling, pt can cope with a short course of NSAIDs - If pain is more intense a corticosteroid injection is done into the subacromial space **Chronic** - Treatment should be directed at the impingement lesion, rather than the calcification - Physical therapy will help avoid a loss of mobility
90
SHOULDER - AC JOINT ARTHRITIS
- Osteoarthritis of the AC joint is a common source of shoulder pain that is often neglected by doctors - Suggested about 60% of elderly people will have x-ray evidence of degenerative changes of the AC joint - Primary OA - Develops as a consequence of constant stress on the joints - Secondary OA - Due to other associated causes like post-trauma or other underlying diseases such as rheumatoid arthritis
91
SHOULDER - AC JOINT ARTHRITIS - RISK FACTORS
- Secondary OA of the AC - Occupational heavy lifting - Manual work - Repetitive micro trauma - Inflammatory arthropathies - Septic arthritis - Instability - Traumatic injury
92
SHOULDER - AC JOINT ARTHRITIS - POPULATION AFFECTED
- Over 50
93
SHOULDER - AC JOINT ARTHRITIS - CLINICAL PRESENTATION
- Pt presents with shoulder pain that is not well localised to the AC joint - Often a dull ache involving the deltoid area that is exacerbated by motion - Shoulder pain on the top of the shoulder is a common symptom - Most planes of motion will cause pain, but horizontal adduction will be most symptom provoking - Pt will often complain of inability to sleep on the affected side - Pt should give nearly full but painful passive ROM - Common for a painful arc in a range greater than that associated with rotator cuff impingement
94
SHOULDER - AC JOINT ARTHRITIS - PROGNOSIS
- The arthritis will gradually become more severe - Treatment options are limited - Initial treatment is similar to that of osteoarthritis in other joints - NSAIDs - Emphasis on activity modification
95
SHOULDER - ROTATOR CUFF TEAR
- Seen in both young and older people - In younger pt there is usually a traumatic injury or a demand for unusual use of the shoulder - As people age the muscle and tendon tissue of the rotator cuff loses some elasticity so becomes more susceptible to injuries
96
SHOULDER - ROTATOR CUFF TEAR - RISK FACTORS
- Age - More common in people over 45 - Some occupations - Jobs that require repetitive overhead arm motions - Certain sports - Baseball - Tennis - Weightlifting - Family history
97
SHOULDER - ROTATOR CUFF TEAR - POPULATION AFFECTED
- Most common in pt over 45 - Can happen to anyone
98
SHOULDER - ROTATOR CUFF TEAR - CLINICAL PRESENTATION
- Most common symptom is pain - Pain is often felt over the outside of the shoulder and upper arm in the deltoid region - Pt will describe it as generalised discomfort that is made worse with specific movements of the shoulder - May also be a loss of motion - Depending on the severity of the tear - Pt may also complain of - Crepitus - Catching - Stiffness - If it is an incomplete tear pain will likely be the most prominent symptom - Decreased strength may also be noted but is not usually pts primary complaint - A complete tear may result in an inability to move the shoulder, but some pt demonstrate minimal functional limitations with a tear
99
SHOULDER - ROTATOR CUFF TEAR - PROGNOSIS
- Nonoperative treatment is recommended for pt with rotator cuff disease who present with pain without dramatic or progressive weakness - Rotator cuff tears do not heal well with time - But rotator cuff tears do not necessarily need to heal in order for the symptoms to resolve - Many people have rotator cuff tears but no symptoms of shoulder pain - Initial treatment is conservative - Physical therapy - NSAIDs - Cortisone injections - In some cases early surgery should be recommended - Especially a traumatic tear in a younger pt
100
SHOULDER - SHOULDER INSTABILITY
- Instability of the GH joint is a common cause of disability and pain in the adolescent and young adult population
101
SHOULDER - SHOULDER INSTABILITY - RISK FACTORS
- Unidirectional instability - Men affected more than women - Trauma - Multidirectional instability - Women affected more than men - Sports that repetitively cycle the GH joint - Swimming - Volleyball
102
SHOULDER - SHOULDER INSTABILITY - POPULATION AFFECTED
- Adolescents and young adults
103
SHOULDER - SHOULDER INSTABILITY - CLINICAL PRESENTATION
- Pt presents with a variety of symptoms - Pain - Varying degrees of instability - The sensation of joint subluxation - Transient neurologic symptoms - Unidirectional anterior instability - Can often remember a specific event that may have brought on the symptoms - Unidirectional instability is usually as a result of significant trauma to the shoulder - Multidirectional instability - Classic complaint is pain
104
SHOULDER - SHOULDER INSTABILITY - PROGNOSIS
- Nonoperative treatment - Multidirectional instability - Pt who have primarily multidirectional instability physical therapy is the main treatment - Physical therapy should be continued for at least 6 months - Pt who have significant discomfort and have difficulty progressing during therapy can be given a short course of analgesic or NSAIDs - This can resolve with age as the shoulder stiffens - Unidirectional instability - Most pt with this have experienced a traumatic anterior dislocation and may require an initial period of sling immobilisation to relieve symptoms - Immobilisation should be brief though - Surgical treatment - If conservative treatments fail to relieve the instability and pt continues to have difficulty with activities of daily living, recreation or occupational duties, surgical treatment is an option
105
SHOULDER - SHOULDER ARTHRITIS
- GH arthritis occurs in up to 20% of adults - Most common type is osteoarthritis but there are also other causes - Rheumatoid arthritis - Inflammatory arthritis - Osteonecrosis - Rotator cuff arthropathy - Posttraumatic or postsurgical arthritis
106
SHOULDER - SHOULDER ARTHRITIS - RISK FACTORS
- Advanced age - Genetics - Increased weight - Joint infection - History of shoulder dislocation - Previous injury - Certain occupations - Heavy construction - Overhead sports
107
SHOULDER - SHOULDER ARTHRITIS - POPULATION AFFECTED
- Over 50
108
SHOULDER - SHOULDER ARTHRITIS - CLINICAL PRESENTATION
- Pain in the affected shoulder is most common complaint - Shoulder stiffness is also a frequent problem - Pt may note a sensation of crepitus with shoulder movement - Symptoms usually begin gradually and are chronic and progressive - Discomfort is typically worsened with activity - Pt may awake in the night from pain - Functional limitations may be present - Inability to perform overhead activities - Reach behind back - Pt history is vital as it can provide important clues as to which type of arthritis it is - GH joint line tenderness is typical - Active and passive ROM is typically restricted, usually in multiple planes
109
SHOULDER - SHOULDER ARTHRITIS - PROGNOSIS
- The arthritis will gradually become more severe, symptoms are usually intermittent and it may take decades for symptoms to become significant - Treatment varies depending on specific etiology - Initial management is typically nonoperative and includes - Modification of activity - Use of NSAIDs - Use of intra-articular corticosteroid injections - Physical therapy
110
SHOULDER - ADHESIVE CAPSULITIS
- Lifetime prevalence of frozen shoulder is estimated to be 2 to 5 percent of the general population - Frozen shoulder is found to affect 8.2% of men and 10.1% of women of working age
111
SHOULDER - ADHESIVE CAPSULITIS - RISK FACTORS
- Age - 40+ - Sex - Females affected more than males - Immobility or reduced mobility - Systemic diseases - Diabetes - Overactive thyroid (hyperthyroidism) - Underactive thyroid (hypothyroidism) - Cardiovascular disease - Parkinson’s disease
112
SHOULDER - ADHESIVE CAPSULITIS - POPULATION AFFECTED
- 40 – 60 years
113
SHOULDER - ADHESIVE CAPSULITIS - CLINICAL PRESENTATION
- Characterised by pain and stiffness which usually resolves itself after about 18 months - Pain gradually increases in severity and often prevents sleeping on the affected side - After several months pain begins to subside - As pain gets better, stiffness becomes more and more of a problem - If untreated, stiffness persists for another 6 – 12 months - Gradually movement is regained but may not return to normal - May be slight muscle wasting - There may be some tenderness, but movements are always limited
114
SHOULDER - ADHESIVE CAPSULITIS - PROGNOSIS
- Conservative treatment with analgesics, anti-inflammatory drugs, local heat and exercise aims at relieving pain and preventing further stiffening while awaiting recovery - Physical therapy and steroid injections are not proven to work - Operative treatment is occasionally called for
115
SHOULDER - DISORDERS OF THE ROTATOR CUFF
- The commonest cause of pain around the shoulder is a disorder of the rotator cuff – rotator cuff syndrome - Rotator cuff syndrome comprises of several conditions - Subacute tendinitis (painful arc syndrome) - Chronic tendinitis (impingement syndrome) - Rotator cuff tears
116
SHOULDER - DISORDERS OF THE ROTATOR CUFF - RISK FACTORS
- Degeneration - Trauma and impingement - Vascular reaction - This process can be summed up as ‘wear, tear and repair’
117
SHOULDER - DISORDERS OF THE ROTATOR CUFF - POPULATION AFFECTED
**Chronic tendinitis** - 40 – 50 years **Rotator cuff tear** - Usually over 45
118
SHOULDER - DISORDERS OF THE ROTATOR CUFF - PAINFULL ARC SYNDROME
**Painful arc syndrome** - Pt develops anterior shoulder pain after vigorous or unaccustomed activity - Shoulder looks normal but is acutely tender along the anterior edge of the acromion
119
SHOULDER - DISORDERS OF THE ROTATOR CUFF - CHRONIC TENDINITIS
**Chronic tendinitis** - Pt gives a history of recurrent attacks of subacute tendinitis, the pain settling down with rest or anti-inflammatory treatment, only to recur when more demanding activities are resumed - Pain is worse at night - Pt cannot lie of affected side often finds it more comfortable to sit up out of bed - A marked feature is coarse crepitation or palpable snapping over the rotator cuff when the shoulder is passively rotated
120
SHOULDER - DISORDERS OF THE ROTATOR CUFF - ROTATOR CUFF TEAR
**Rotator cuff tear** - Most advanced stage of the disorder is progressive fibrosis and disruption of the cuff resulting in either a partial or full thickness tear - Pt has history of pain with increasing stiffness and weakness - Partial tears - Not easily detected - Continuity of the remaining cuff fibres permits active abduction with a painful arc - If in doubt pain can be eliminated by injecting local anaesthetic into the subacromial space - If abduction is now possible the tear must only be partial - Full thickness tears - There is sudden pain and pt is unable to abduct the arm - Few weeks full tear - Pain has subsided, Abduction is impossible, Attempting abduction produces a characteristic shrug
121
SHOULDER - DISORDERS OF THE ROTATOR CUFF - PROGNOSIS - CONSERVATIVE TREATMENT
**Conservative treatment** - Uncomplicated impingement syndrome is often self-limiting, and symptoms settle down after aggravating activity is eliminated - Physiotherapy should be done to help the pt through the painful healing phase - Short course of NSAIDs sometimes brings relief - If none of this works, an injection of corticosteroids into the subacromial space can help - Modification of activity should be done for 6 months
122
SHOULDER - DISORDERS OF THE ROTATOR CUFF - PROGNOSIS - SURGICAL TREATMENT
**Surgical treatment** - If pt has useful ROM, adequate strength and well controlled pain, no operative measures are needed - If symptoms do not subside after 3 months of conservative treatment, operation can be considered - Indication is more pressing if there is evidence of a full tear in a young person - The procedure allows for early rehab
123
SHOULDER - DISORDERS OF THE ROTATOR CUFF - PROGNOSIS - REPAIRING TEARS
**Repair of tears** - Indications for operative repair are - Chronic pain - Weakness of the shoulder - Significant loss of function - The younger and more active a pt is, the greater justification for surgery - Procedure is either open or an arthroscopy - Advantages of arthroscopy - Less soft tissue damage - Faster rehab - Better cosmetic appearance
124
SHOULDER - LESIONS OF THE BICEPS TENDON - TENDINITIS
**Tendinitis** - Tendon of long head of biceps lies adjacent to the rotator cuff and may be involved in the impingement syndrome
125
SHOULDER - LESIONS OF THE BICEPS TENDON - TORN OF LONG HEAD BICEPS
**Torn long head of biceps** - Degeneration and disruption of the tendon of the long head of biceps is common and is often associated with rotator cuff problems
126
SHOULDER - LESIONS OF THE BICEPS TENDON - RISK FACTORS
- Males over 30 - Smoking - Corticosteroid injections
127
SHOULDER - LESIONS OF THE BICEPS TENDON - POPULATION AFFECTED - TENDINITIS
**Tendinitis** - Older adults
128
SHOULDER - LESIONS OF THE BICEPS TENDON - POPULATION AFFECTED - TORN LONG HEAD OF BICEPS
**Torn long head of biceps** - Middle aged or elderly
129
SHOULDER - LESIONS OF THE BICEPS TENDON - CLINICAL PRESENTATION - TENDINITIS
**Tendinitis** - Pain and tenderness are sharply localised to the bicipital groove - Stressing the biceps tendon will provoke pain - Can do this by resisting elbow flexion and supination
130
SHOULDER - LESIONS OF THE BICEPS TENDON - CLINICAL PRESENTATION - TORN LONG HEAD OF BICEPS
**Torn long head of biceps** - While lifting a heavy object pt feels something snap - The shoulder then aches for a time and bruising appears over the front of the arm - Soon the ache subsides and good function returns but when the elbow is flexed actively the belly of the muscle contracts into a prominent lump
131
SHOULDER - LESIONS OF THE BICEPS TENDON - PROGNOSIS - TENDINITIS
**Tendinitis** - Rest - Local heat - Deep transverse frictions - If recovery is delayed a corticosteroid injection can help
132
SHOULDER - LESIONS OF THE BICEPS TENDON - PROGNOSIS - TORN LONG HEAD OF BICEPS
**Torn long head of biceps** - Function is rarely disturbed so treatment is unnecessary - Treatment can be given if associated rotator cuff symptoms need attention
133
SHOULDER - SLAP LESION
- A fall on an outstretched arm can sometimes damage the superior part of the glenoid labrum anteriorly and posteriorly (SLAP)
134
SHOULDER - SLAP LESION - RISK FACTORS
- Overhead sports - Contact sports
135
SHOULDER - SLAP LESIONS - POPULATION AFFECTED
- 30 – 50
136
SHOULDER - SLAP LESIONS - CLINICAL PRESENTATION
- History of a fall followed by pain in the shoulder - As initial symptoms settle, the pt continues to experience a painful ‘click’ on lifting the arm above shoulder height - This is also experienced with a loss of power when using the arm in this position - Pt may also complain of an inability to throw with that arm
137
SHOULDER - SLAP LESION - PROGNOSIS
- Good - Lesion is treated by re-attachment or debridement
138
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - ANTERIOR DISLOCATION
- **Anterior dislocation** - Most common - over 95% of cases - Usually follows an acute injury where the arm is forced into abduction, external rotation and extension
139
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - RECURRENT DISLOCATION
- **Recurrent dislocation** - The labrum and capsule are often detached from the anterior rim of the glenoid - Pt may describe a ‘catching’ sensation followed by numbness or weakness - 1/3 of pts are under 30, 1/5 of pts are over 50
140
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - ANTERIOR SUBLUXATION
- **Anterior subluxation** - May follow and alternate with episodes of dislocation - Joint feels as if it pops out briefly during certain actions (only becomes partially displaced) - Pt may describe ‘catching’ sensation, followed by ‘numbness’ or ‘weakness’ – dead arm syndrome
141
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - POSTERIOR DISLOCATION
- **Posterior dislocation** - Rare - Usually due to a violent jerk in an unusual position, e.g. after an epileptic fit
142
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - ATRAUMATIC INSTABILITY
- **Atraumatic instability** - Associated with capsular and ligamentous laxity - This is not the same as true instability
143
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - RISK FACTORS
- Male - Age - Young adults or 50+
144
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - POPULATION AFFECTED
- Young adults - People over 50
145
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - CLINICAL PRESENTATION - ANTERIOR INSTABILITY
**Anterior instability** - Usually occurs as sequel to acute anterior dislocation, with detachment or stretching of the glenoid labrum and capsule - In those over 50, dislocation is often associated with a rotator cuff tear - Pt describes an initial episode of the shoulder coming out of the joint following an injury - After the initial injury pt complains of the shoulder repeatedly ‘coming out of joint’ during over-arm movements, each time having to manipulate it back into place
146
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - CLINICAL PRESENTATION - POSTERIOR INSTABILITY
**Posterior instability** - Sometimes persists after an acute posterior dislocation - Usually takes the form of recurrent subluxation rather than full dislocation - The shoulder subluxate when the arm is held in flexion and internal rotation
147
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - CLINICAL PRESENTATION - ATRAUMATIC INSTABILITY
**Atraumatic instability** - Pt complains of the shoulder going ‘out of joint’ with remarkable ease - Can occur in athletes who overload and fatigue the stabilising muscles around the shoulder leading to pain and subluxation in various directions - Another form is associated with individuals who are able to voluntarily subluxate or dislocate their shoulders
148
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - PROGNOSIS - ANTERIOR DISLOCATION
**Anterior instability** - Indications for operative treatment are - Frequent dislocations, especially if painful - Fear or recurrent subluxation - Dislocation sufficient to prevent participation in everyday activities
149
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - PROGNOSIS - POSTERIOR INSTABILITY
**Posterior instability** - Treatment is usually conservative - Muscle strengthening exercises and voluntary control of the joint - Operative reconstruction is only needed if disability is marked - No gross joint laxity - There is a structural abnormality found on a CT or MRI scan
150
SHOULDER - CHRONIC INSTABILITY OF THE SHOULDER - PROGNOSIS - ATRAUMATIC INSTABILITY
**Atraumatic instability** - Usually treated by physiotherapy to strengthen the muscles and to restore proprioception - Occasionally surgery is needed to tighten the capsule (for athletes) - Treatment for individuals who can voluntarily subluxate involves physiotherapy and sometimes psychological counselling
151
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT
**Tuberculosis arthritis** - TB arthritis in the shoulder is uncommon **Rheumatoid arthritis** - The AC joint, the GH joint and various synovial pouches around the shoulder are frequently involved in rheumatoid disease **Osteoarthritis** - GH OA is usually secondary to other fairly obvious disorders
152
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - RISK FACTORS
- Advancing age - Genetics - Obesity
153
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - POPULATION AFFECTED
**TB arthritis** - Adults **Osteoarthritis** - 50 – 60
154
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - CLINICAL PRESENTATION - TUBERCULOSIS ARTHRITIS
**Tuberculosis arthritis** - Usually starts as osteitis - May proceed to abscess and sinus formation - Pt presents with constant ache and stiffness lasting many months - Striking feature is muscle wasting around the shoulder - There is diffuse warmth and tenderness - All movements are limited and painful
155
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - CLINICAL PRESENTATION - RHEUMATOID ARTHRITIS
**Rheumatoid arthritis** - Pt usually has generalised arthritis - Pt complains of pain in the shoulder and difficulty with tasks that involve lots of movement - Active movements are limited - Passive movements are painful and marked with crepitus
156
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - CLINICAL PRESENTATION - OSTEOARTHRITIS
**Osteoarthritis** - Pt complains of pain in shoulder - May have a history of previous shoulder problems - Most typical sign is progressive restriction of shoulder movements
157
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - PROGNOSIS - TUBERCULOSIS ARTHRITIS
**Tuberculosis arthritis** - Systemic treatment with antituberculosis drugs - Shoulder should also be rested until acute symptoms have settles - After acute symptoms have subsided, movement is encouraged and as long as the articular cartilage is not destroyed prognosis for painless function is good - Joint should be arthrodesed if there are repeated flares or if the articular surfaces are extensively destroyed
158
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - PROGNOSIS - RHEUMATOID ARTHRITIS
**Rheumatoid arthritis** - Corticosteroid may be injected into the joint and the subacromial bursa if general measures do not control synovitis - If synovitis persists, surgical options are available
159
SHOULDER - DISORDERS OF THE GLENOHUMERAL JOINT - PROGNOSIS - OSTEOARTHRITIS
**Osteoarthritis** - Analgesics and anti-inflammatory drugs relieve pain - Exercises may improve mobility - Most pt manage to live with the restrictions (imposed by the stiffness) as long as pain is not severe
160
SHOULDER - RAPIDLY DESTRUCTIVE SHOULDER ARTHROPATHY
- A form of arthritis - Crystal induced, rapidly progressive arthropathy - Sometimes associated with massive tears of the rotator cuff
161
SHOULDER - RAPIDLY DESTRUCTIVE SHOULDER ARTHROPATHY - RISK FACTORS
- Women affected more - Previous shoulder trauma - Especially rotator cuff injuries
162
SHOULDER - RAPIDLY DESTRUCTIVE SHOULDER ARTHROPATHY - POPULATION AFFECTED
- Mainly older women - Over 70
163
SHOULDER - RAPIDLY DESTRUCTIVE SHOULDER ARTHROPATHY - CLINICAL PRESENTATION
- Pt presents with swelling of the shoulder - X-rays show a bizarrely destructive form of arthritis - Suggested this is a crystal-induced, rapidly progressive arthropathy - Sometimes associated with massive tears of the rotator cuff
164
SHOULDER - RAPIDLY DESTRUCTIVE SHOULDER ARTHROPATHY - PROGNOSIS
- Not great - There is no treatment - Arthroplasty may relieve pain but will not improve function because the joint is unstable
165
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE
- Many people are affected by disorders of the scapula and clavicle - Disorders can be congenital or due to old age or other risk factors.
166
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - RISK FACTORS - WINGED SCAPULA
**Winged scapula** - Damage to the long thoracic nerve - Injury to the brachial plexus or the 5, 6, and 7 cervical nerve roots - Viral infections of the nerve roots - Certain types of muscular dystrophy
167
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - RISK FACTORS - OA OF THE AC JOINT
**Osteoarthritis of the AC joint** - Older age
168
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - POPULATION AFFECTED
- Degenerative conditions (e.g. OA of the AC) are experienced more by older people - Klippel-Feil syndrome and Sprengel’s shoulder are congenital disorders
169
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - CONGENITAL ELEVATION OF THE SCAPULA
**Congenital elevation of the scapula (Sprengel’s shoulder)** - Shoulder on the affected side is elevated - Scapula looks and feels abnormally high, smaller than usual and somewhat prominent - Movements are painless but abduction may be restricted - Associated deformities such as fusion of cervical vertebrae, kyphosis or scoliosis may be present
170
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - KLIPPEL-FEIL SYNDROME
**Klippel-Feil syndrome** - Rare congenital disorder - Bilateral failure of scapular descent - Fusion of several cervical vertebrae - Neck is unusually short and may be webbed - Cervical mobility is restricted
171
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - WINGED SCAPULA
**Winged scapula** - Scapula juts out under the skin - Due to a weakness in the serratus anterior - May cause asymmetry of the shoulders but is often not apparent till pt tries to contract serratus anterior against resistance
172
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - GRATING SCAPULA
**Grating scapula** - Found in about 1/3 of normal people - Cause not usually found - Occasionally x-ray will show osteochondroma - Involves popping, grating, grinding or snapping of bones and tissue in the shoulder blade area when lifting and moving the arm
173
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - AC INSTABILITY
**Acromioclavicular instability** - Common condition - Results from dislocation of the AC joint and rupture of ligaments which surround the outer end of the clavicle - Pt may complain of pain and weakness during strenuous activities with the arm above shoulder height - On exam there is a fairly obvious bump over the AC joint and pressure over the joint may be painful
174
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - CLINICAL PRESENTATION - OA OF THE AC JOINT
**Osteoarthritis of the acromioclavicular joint** - Develops spontaneously - Common in older people - When it occurs in younger people it may be due to previous injuries or repetitive stress - Pt complains of pain over top of the shoulder - Particularly whilst using the arm above shoulder height - Tenderness and swelling localised to the AC joint
175
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - CONGENITAL ELEVATION OF THE SCAPULA
- Mild cases are best left untreated - Marked limitation of abduction or severe deformity may need an operation to lower the scapula
176
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - KLIPPEL-FEIL SYNDROME
- Usually left untreated
177
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - WINGED SCAPULA
- Some disorders causing winged scapula are self-limiting and the condition gradually improves - Even without improvement, disability is usually slight and is best accepted
178
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - GRATING SCAPULA
- No treatment needed
179
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - AC INSTABILITY
- Treatment is often unnecessary as the condition causes little disability during non-strenuous activities - But certain types of work activity may be seriously affected - In such cases surgery should be considered
180
SHOULDER - DISORDERS OF THE SCAPULA AND CLAVICLE - PROGNOSIS - OA OF THE AC JOINT
- Analgesics - Corticosteroid injections - If these don’t work, pain may be relieved by excision of the lateral end of the clavicle
181
SHOULDER - AROM - FLEXION - MUSCLES ACTIVATED
Deltoid (anterior fibres) Biceps brachii Pectoralis major Coracobrachialis (1st 60 only)
182
SHOULDER - AROM - FLEXION - TISSUES STRETCHED
Latissimus dorsi Teres major Pectoralis major (low fibres) Triceps brachii (long head) Inferior GH capsule Conoid ligament
183
SHOULDER - AROM - FLEXION - TISSUES COMPRESSED
Supraspinatus tendon Subdeltoid bursa Upper GH joint capsule
184
SHOULDER - AROM - EXTENSION - MUSCLES ACTIVATED
Deltoid (posteiror fibres) Latissimus dorsi Teres major/minor Infraspinatus Triceps brachii
185
SHOULDER - AROM - EXTENSION - TISSUES STRETCHED
Deltoid (anterior fibres) Biceps brachii Pectoralis major Anterior GH capsule
186
SHOULDER - AROM - EXTENSION - TISSUES COMPRESSED
Posterior GH capsule
187
SHOULDER - AROM - ABDUCTION - MUSCLES ACTIVATED
Supraspinatus Deltoid (middle fibres) Trapezius Serratus anterior
188
SHOULDER - AROM - ABDUCTION - TISSUES STRETCHED
Latissimus dorsi Teres major Pectoralis major (lower fibres) Triceps brachii (long head) Inferior GH capsule Conoid ligament
189
SHOULDER - AROM - ABDUCTION - TISSUES COMPRESSED
Supraspinatus tendon Subdeltoid bursa Upper GH joint capsule
190
SHOULDER - AROM - ADDUCTION - MUSCLES ACTIVATED
Deltoid (anterior fibres) Pectoralis major Latissimus dorsi Teres major Coracobrachialis Trapezius
191
SHOULDER - AROM - ADDUCTION - TISSUES STRETCHED
Deltoid (middle fibres) Posterior GH capsule
192
SHOULDER - AROM - ADDUCTION - TISSUES COMPRESSED
Pectoralis major AC & SC joint Anterior GH capsule
193
SHOULDER - AROM - EXTERNAL ROTATION - MUSCLES ACTIVATED
Infraspinatus Teres minor Posterior deltoid
194
SHOULDER - AROM - EXTERNAL ROTATION - TISSUES STRETCHED
Pectoralis major Subscapularis Anterior GH capsule
195
SHOULDER - AROM - EXTERNAL ROTATION - TISSUES COMPRESSED
Posterior GH capsule
196
SHOULDER - AROM - INTERNAL ROTATION - MUSCLES ACTIVATED
Pectoralis major Subscapularis Anterior deltoid Teres major Latissimus dorsi
197
SHOULDER - AROM - INTERNAL ROTATION - TISSUES STRETCHED
Infraspinatus Teres minor Posterior deltoid Posterior GH capsule
198
SHOULDER - AROM - INTERNAL ROTATION - TISSUES COMPRESSED
Anterior GH capsule
199
DELTOID - ORIGIN
Lateral 1/3 of clavicle Acromion Spine of scapula
200
DELTOID - INSERTION
Deltoid tuberosity of humerus
201
DELTOID - ACTION
**Anterior** - flexion, horizontal adduction and internal rotation of the shoulder **Middle** - Abduction of the shoulder **Posterior** - extension, horizontal abduction and lateral rotation of the shoulder
202
DELTOID - INNERVATION
Axillary nerve (C5-C6)
203
DELTOID - TRIGGER POINT REFERRAL
Referal local to the area
204
DELTOID - STRETCH
**Anterior** - extend shoulder to stretch anterior **Middle** - Pull and adduct shoulder inferiorly behind back to stretch middle **Posterior** - Pull shoulder anteriorly across the body to stretch posterior
205
DELTOID - STRENGTHEN
Resisted shoulder abduction, flexion or extension Front raises Lateral raises
206
ROTATOR CUFF MUSCLES
Supraspinatus Infraspinatus Teres minor Subscapularis Coracobrachialis
207
SUPRASPINATUS - ORIGIN
Supraspinous fossa of scapula
208
SUPRASPINATUS - INSERTION
Greater tubercle of humerus (superior facet)
209
SUPRASPINATUS - ACTION
Abduction of shoulder Stabilises GH joint
210
SUPRASPINATUS - INNERVATION
Suprascapular nerve (C5-C6)
211
SUPRASPINATUS - TRIGGER POINT REFERRAL
Felt as a deep ache in the mid-deltoid region of the shoulder Pain often extends down the lateral arm and upper forearm Pain may concentrate at the lateral epicondyle
212
SUPRASPINATUS - STRETCH
Adduct shoulder and pull arm inferiorly behind back Adduct shoulder and pull arm inferiorly in front of body
213
SUPRASPINATUS - STRENGTHEN
Resisted shoulder abduction Lateral raises
214
INFRASPINATUS - ORIGIN
Infraspinous fossa Inferior portion of spine of scapula
215
INFRASPINATUS - INSERTION
Greater tubercle of humerus
216
INFRASPINATUS - ACTION
Lateral rotation of shoulder Stabilises GH joint
217
INFRASPINATUS - INNERVATION
Suprascapular nerve (C5-C6)
218
INFRASPINATUS - TRIGGER POINT REFERRAL
Occur mainly in the muscle belly Primary referral is to the anterior deltoid region and in the shoulder joint Pain may extend down front and lateral aspect of arm and forearm and sometimes include the radial half of hand
219
INFRASPINATUS - STRETCH
While seated, place both hands on waist with thumbs forward, bend forward and let elbows fall toward floor
220
INFRASPINATUS - STRENGTHEN
Lying lateral rotation
221
TERES MINOR - ORIGIN
Superior lateral border of scapula
222
TERES MINOR - INSERTION
Greater tubercle of humerus
223
TERES MINOR - ACTION
Lateral rotatioon of shoulder Stabilises GH joint
224
TERES MINOR - INNERVATION
Axillary nerve (C5-C6)
225
TERES MINOR - TRIGGER POINT REFERRAL
Primary referral is over a very small area of the back and shoulder, near the lateral border of the scapula; the back of the arm, deep in the posterior deltoid
226
TERES MINOR - STRETCH
While seated, place both hands on waist with thumbs forward, bend forward and let elbows fall to the floor
227
TERES MINOR - STRENGTHEN
Resisted lateral rotation Lying lateral rotation
228
SUBSCAPULARIS - ORIGIN
Subscapular fossa of scapula
229
SUBSCAPULARIS - INSERTION
Lesser tubercle of humerus
230
SUBSCAPULARIS - ACTION
Medial rotation of the shoulder Stabilises GH joint
231
SUBSCAPULARIS - INNERVATION
Upper and lower subscapular nerves (C5-C6)
232
SUBSCAPULARIS - TRIGGER POINT REFERRAL
Pain referral is over the posterior axillary fold and medial arm Sometimes pain refers down to the wrist and over the mid deltoid
233
SUBSCAPULARIS - STRETCH
Abduct and externally rotate shoulders above head against shair or bench, pull body inferiorly
234
SUBSCAPULARIS - STRENGTHEN
Resisted shoulder medial rotation Lying medial rotation Standing medial rotation
235
CORACOBRACHIALIS - ORIGIN
Coracoid process of scapula
236
CORACOBRACHIALIS - INSERTION
Medial shaft of humerus
237
CORACOBRACHIALIS - ACTION
Flexion and adduction of shoulder Horizontal adduction of shoulder
238
CORACOBRACHIALIS - INNERVATION
Musculocutaneous nerve (C5-C7)
239
CORACOBRACHIALIS - TRIGGER POINT REFERRAL
Usually referred over anterior deltoid and down posterior arm to the dorsum of hand May extend to the tip of the middle finger Referral may skip elbow and wrist
240
CORACOBRACHIALIS - STRETCH
Standing against wall or door with shoulder extended, slightly abducted and externally rotated
241
CORACOBRACHIALIS - STRENGTHEN
Front raises Fly Bench press
242
TERES MAJOR - ORIGIN
Inferior, lateral border of scapula
243
TERES MAJOR - INSERTION
Medial lip of bicipital groove of humerus
244
TERES MAJOR - ACTION
Medial rotation and adduction of shoulder Extension of shoulder from a flexed position
245
TERES MAJOR - INNERVATION
Lower subscapular nerve (C5-C7)
246
TERES MAJOR - TRIGGER POINT REFERRAL
Feeling of sharp pain in posterior shoulder and arm Pain often described in deltoid muscle
247
TERES MAJOR - STRETCH
Abduct and externally rotate shoulders above head against wall or door, pull body inferiorly
248
TERES MAJOR - STRENGTHEN
Medial rotation of the shoulder Pull over Chin up Swimming breast stroke
249
SERRATUS ANTERIOR - ORIGIN
Ribs 1-9
250
SERRATUS ANTERIOR - INSERTION
Costal surface of medial border of scapula
251
SERRATUS ANTERIOR - ACTION
Protraction (abduction) and upward rotation od scapula Stabilises scapula for upper extremity movements
252
SERRATUS ANTERIOR - INNERVATION
Long thoracic nerve (C5-C7)
253
SERRATUS ANTERIOR - TRIGGER POINT REFERRAL
Referral is usually over the lateral inferior portion of the scapula Pt may also experience pain while exhaling
254
SERRATUS ANTERIOR - STRETCH
Shoulders extend with scapulas fully retracted and stick chest out
255
SERRATUS ANTERIOR - STRENGTHEN
Boxing/punching Push ups Incline shoulder raises Resisted shoulder protraction
256
PECTORALIS MAJOR - ORIGIN
**Clavicular** - medial 1/2 of clavicle **Sternal** - anterior sternum **Costal** - costal cartilage ribs 1-6
257
PECTORALIS MAJOR - INSERTION
Lateral lip of bicipital groove of humerus (crest of the greater tubercle)
258
PECTORALIS MAJOR - ACTION
Adduction and medial rotation of shoulder Horizontal adduction of shoulder Flexion of shoulder (clavicular portion)
259
PECTORALIS MAJOR - INNERVATION
Medial and lateral pectoral nerve (C8-T1)
260
PECTORALIS MAJOR - TRIGGER POINT REFERRAL
Pain may extend up over subclavicular area and may cover the entire ipsilateral pectoral and anterior deltoid region Pain may radiate down the ulnar side, elbow, forearm and hypothenar side of hand (last 3 digits)
261
PECTORALIS MAJOR - STRETCH
**Lower** - elbow flexed, shoulder abduct 150 and extend against door or wall **Middle** - elbow flexed, shoulder abducted 100 and extend against the door or wall **Upper** - elbow flexed, shoulder adducted 60 and extended against the door or wall
262
PECTORALIS MAJOR - STRENGTHEN
Push ups Flys Pull over Chest dips Bench press - incline for upper, decline for lower
263
PECTORALIS MINOR - ORIGIN
Ribs 3-5 (anterior lateral portion)
264
PECTORALIS MINOR - INSERTION
Coracoid process of scapula
265
PECTORALIS MINOR - ACTION
Stabilises scapula for arm movements Depresses and downwardly rotates scapula Elevates rib 3-5
266
PECTORALIS MINOR - INNERVATION
Medial pectoral nerve (C8-T2)
267
PECTORALIS MINOR - TRIGGER POINT REFERRAL
Pain is most prominent over the anterior deltoid but may extend up over subclavicular area and may cover the entire ipsilateral pectoral and anterior deltoid region
268
PECTORALIS MINOR - STRETCH
Shoulders extended with scapulas fully retracted, stick out chest
269
PECTORALIS MINOR - STRENGTHEN
Pectoralis minor is recruited during most shoulder movements and pec major exercises
270
LEVATOR SCAPULAE - ORIGIN
TPs of C1-C2 vertebrae Posterior tubercles of TPs of C3-C4
271
LEVATOR SCAPULAE - INSERTION
Superior angle of scapula Medial border of scapula superior to spine of scapula
272
LEVATOR SCAPULAE - ACTION
Elevates and downwardly rotates shoulder girdle at AC and SC joints Extends and laterally flexes neck at cervical vertebral joints
273
LEVATOR SCAPULAE - INNERVATION
Dorsal sub scapular nerve (C5) Anterior rami of C3 - C4