Shoulder Flashcards
What directions does the humerus face?
Medially
Posteriorly
Superiorly
What angle does the head of humerus form with the long axis of the humerus?
130-150 degrees
The head of the humerus is angled posteriorly ___ degrees
30-40
What directions does the glenoid fossa face?
Laterally
Superiorly
Anteriorly
How much of the surface of the humeral head does the glenoid fossa cover?
1/3 - 1/4
Labrum of the GH Joint
Fibrocartilagenous ring
Makes glenoid fossa ~50% deeper
Attached to margin of glenoid cavity and joint capsule
Lateral portion of the biceps anchors superiorly
Posterior Capsule of the GH Joint
Flexion
Abduction
IR
Anterior GH Ligament
Extension
Abduction
ER
Inferior GH Ligament
Extension
Abduction
ER
*Primary restraint against anterior and posterior dislocations
Middle GH Ligament
Flexion
ER
Coracohumeral Ligament Posterior Band
Flexion of GH
Inferior and posterior translation of humeral head
Coracohumeral Ligament Anterior Band
Extension of GH
Inferior and posterior translation of humeral head
Suprahumeral Space Size and Boundaries
9-15 mm
Inferior: tuberosity of the humeral head
Anteromedial: coracoid process
Superior: coracoacromial arch
Suprahumeral Space Contents (5)
Long head of biceps tendon Superior joint capsule Supraspinatus Upper margins subscapularis and infraspinatus Subacromial bursa
GH Open Packed Position
55 degrees abduction
30 degrees horizontal adduction
Neutral rotation
GH Closed Packed Position
Full abduction
Full ER
GH Capsular Pattern
ER > abduction > IR > flexion
The AC Joint must rotate approximately ___ degrees for full elevation to occur; if this does not happen, elevation is limited to ____
40-50 degrees
~110 degrees
Coracoclavicular Ligaments
Arm elevation resulting in posterior rotation at SC joint
AC Open Packed Position
Arm by the side
AC Closed Packed Position
90 degrees GH abduction
AC Capsular Pattern
Pain at extremes of ROM
Especially horizontal adduction and full elevation
Sternoclavicular Ligamentous Support
Anterior and posterior sternoclavicular ligaments
Interclavicular ligament
Costoclavicular ligament
SC Open Packed Position
Arm by side
SC Closed Packed Position
Maximum arm elevation and protraction
SC Capsular Pattern
Pain at extremes ROM
Especially full arm elevation and horizontal adduction
Scapulothoracic Joint during full arm elevation
15-25 degrees ER
60 degrees upward rotation
15-30 degrees posterior tilt
Scapulothoracic Joint Open Packed Position
Arm by the side
–Scapula in 30-45 deg IR, slight upward rot, 5-20 ant tilit
NOTE: no capsular pattern or closed packed position
Biomechanics of Elevation 0-90
- Supraspinatus initiates abduction
- Remaining RC muscles pull humeral head into glenoid
- ~20 deg: scapular upward rot with concurrent clavicular elevation and axial rotation
- 90 deg: upper extreme of GH abduction is reached and clavicular elevation ceases (costoclavicular lig tension)
- Scapula upwardly rotated 30 degrees
Biomechanics of Elevation 90-150
-Scapula upwardly rotates 60 degrees
-Scapular contribution peaks between 90-140 degrees
-Upward rotation accom at SC and AC by:
30-40 deg posterior clavicular axial rotation
30-36 deg clavicular elevation
Biomechanics of Elevation 150-180
Abduction >150 requires upper thorax/Cspine motion
Bilateral abduction requires thoracic ext and increased lumbar lordosis
Adhesive Capsulitis
Restriction in active AND passive ROM
Female, >40, trauma, diabetes, prolonged inflamm, thyroid disease, stroke/MI, autoimmune disease
Synovial inflammation w/ reactive capsular fibrosis
Can take 1-3 years to resolve
Adhesive Capsulitis Stage 1
Mild signs/symptoms <3 months duration, loss of motion
at this stage is due to pain and not capsular contracture
Capsular Pattern, achy at rest and sharp at extreme ROM, pain with palpation of ant/post capsules, pain radiates to deltoid insertion
Adhesive Capsulitis Stage 2
“Freezing phase”, 3-9 mo, motion loss reflects loss of capsular volume and response to pain
Pain with palpation of ant/post capsules, radiates to deltoid insertion, loss of motion in all planes, pain in all parts of range
Adhesive Capsulitis Stage 3
“Frozen stage”, 9-14 mo, synovial thickening and dense
collagenous tissue
Painful phase has resolved, stiff shoulder, poor scapulohumeral rhythm during arm elevation, dominant upper trapezius, decreased inferior glide GH
Adhesive Capsulitis Stage 4
“Thawing stage”, capsular remodeling
Slow/steady recovery ROM, capsular end-feel reached before pain
Adhesive Capsulitis Treatment
Acute phase: relieve pain and gentle stretch to capsule
Subacute phase: more aggressive ROM, strengthen
Stages 3/4: Grade IV mobs, low load/long dur stretch
GH Instability
Abnormal symptomatic motion of GH joint that affects normal joint kinematics and results in pain, subluxation, or dislocation
GH Subluxation
Joint contact lost but capsule not necessarily torn, might just be stretched
GH Dislocation
Complete separation of joint surfaces
*Usually anterior
Bankart Lesion/Repair
Avulsion of the anterior inferior labrum from the glenoid rim
*Anterior dislocation, Inferior GH ligament torn
Reattachment of humeral insertion of subscapularis and labrum to anterior glenoid
Tighten anterior capsule
Lose 12 degrees ER post procedure
Hill-Sachs Lesion
Compression fracture of the posterior humeral head at the site where the humeral head impacted the inferior glenoid rim
SLAP Lesion
Superior labral lesion that is both anterior and posterior
Insertion of biceps pulls associated portion of superior labrum away creating bucket-handle lesion
AC Joint Sprain
Acute: fall onto shoulder with arm adducted at side
Chronic: general OA, inflamm arthritis, mechanical probs
RC Tear Mechanisms
Compression: reduction size of subacromial space
Tensile overload: throwing, hammering
Macrotrauma
RC Examination
Painful arc: supraspinatus pain during abduction/scaption from 50-130 degrees
Resisted movement:
-Supraspinatus: abduction and ER
-Infraspinatus: ER
Tendonitis: full active AND passive ROM
Tear: humerus higher on affected side (deltoid pulls up), palpable defect at greater tuberosity, muscle atrophy, reverse scapulohumeral rhythm
Subacromial Impingement Syndrome
Increased superior translation of humeral head –> decreased space in coracoacromial arch and produces compression of suprahumeral structures
Primary Impingement
Intrinsic degenerative process in structures of subacromial space
Anterior impingement
Limited horizontal abduction, IR
Posterior capsule tightness
Secondary Impingement
Lesser tuberosity of humerus encroaches on coracoid process
Coracoid impingement
History of traumatic instability, labrum damage, and/or posterior defect of humeral head
Limited IR
Excessive ER
Anterosuperior humeral head migration (poor RC balance)
Shoulder Arthritis
Humeral head migrating superior–>degeneration
Loss of ROM and strength
Total shoulder arthroplasty
Replace glenoid fossa and head of humerus
Hemiarthroplasty
Replace head of humerus
Reverse total shoulder
Inverted prosthesis so ball is on the scapula and concavity is on humerus
Creates new line of force when RC is not slavagable
Subacromial-Subdeltoid Bursitis
Common with inflammatory arthritis
“Aching” over deltoid region
Rapid onset with activity
Pain with passive abduction at 180 deg, passive IR, passive horizontal adduction
Painful arc
Noncapsular pattern
Palpation distal to AC joint with shoulder in extension
Three types of Bursitis
Related to activity/trauma
Calcific due to little bone projections from acromion
Infectious
How do you differentiate bursitis and tendonitis?
If always able to reach overhead without restriction in motion: tendonitis
Clavicle fracture
Childhood FOOSH or direct blow Difficulty elevating arm >60 Painful horizontal adduction Clavicular deformity
Proximal Humerus Fractures
Direct blow to ant, lat, or posterolateral humerus or FOOSH
Osteopenic bone with minimal trauma
Lung metastasis
Scapular Fracture
Direct blow or trauma
Brachial Plexus Injury
Entrapment from "cervical rib" Stretch injury Radiation Clavicular fractures Compression by soft tissue (scalenes, pec minor)
Thoracic Outlet Syndrome
Brachial plexus AND subclavian artery
Compression of tight muscles (scalenes, pec minor) or clavicle and first rib
Axillary nerve injury
Decreased abduction strength (deltoid)
Decreased ER and elbow ext strength (teres minor, triceps)
Varying loss of sensation
Reflex Sympathetic Dystrophy
“Complex Regional Pain Syndrome”
Associated with nerve trauma Intense, prolong pain out of proportion to cause Night pain Psychological disturbances Discoloration Hypersensitivity of skin Moist skin Chronic edema Atrophy Weakness
Reflex Sympathetic Dystrophy Stages
I (acute): burning pain, tenderness, swelling, vasomotor
changes
II: persistent aching, swelling w/ hardening, skin/nail bed
changes
III: skin and subcutaneous atrophy, development
contractors
