Shoulder Flashcards
Scapula position on thorax
Sup at second thoracic vert
Inf at seventh thoracic vert
30-45 set in coronal plane
Shoulder ligaments and restrictions on motion
Superior and anterior gh jt.
1) superior - restraint to inf translation in addicted position at side.
2) middle- anterior translation in mid range abd up to 45/ limits ER with arm at side.
3) inferior- (ant and post band and hammock) limits ant and post translation at 90 abd/. Also wraps around to Limit translation during rotation
Clavicle and joint arthrokinematics and important ligaments
Saddle
Medial: concave in a/p, convex inf/sup
Posterior stereoclvicular lig- stab ant/post translation
Lateral: 3 degrees of freedom
Conoid and trapezoid (cc lig)- stab medial to ac jt
Supraspinatus role in rtc force couple
Counteract deltoid and approximate gunmetal head
Upper trap and serratus ant force couple 4 crucial functions
1) scap rot for glenoid positioning
2) length tension relationship for deltoid
3) prevents impingement of rtc
4) stable scapular base to enable appropriate rtc mm recruitment
Mech of secondary impingement
Above 90 rhythm relies on sa, lt, mt which have decreased levels of firing
Ant/post rtc force couple
Results in inf dynamic stability and concavity-compression mechanism
Mid range of elevation
Deficts common in throwing athletes
Impingement site of suprascapular nerve
Suprascapular notch and spingolenoid notch and paralabral cyst with labral lesions
ID with scalloping of infraspinatus, only if at spingolenoid notch
3 primary scapular conditions
Inferior angle scapular dysfunction- ant tip of scapula, common with rtc impingement
Medial border dysfunction- IR of scapula in transverse plane, common with gh instability, “antetilting”
Superior scapular dysfunction- early/excessive sip scap elevation, common with rtc weakness and force couple imbalances
SAT, SRT, and flip tests
SAT 77%-91%
SRT- manual scap retraction during difficult movement
Flip- restated ER medial border away from thorax (SA and trap force couple)
Loses of IR
Common in overhead.
Secondary to post capsule tightness which can lead to ant shear of humerus and increased superior migration of general head with shoulder elevation.
Throwing phase peak stress on external rotators
At Follow through phase
Strength test rtc
Supra- full can
Infra- 0 elevation, 45 IR from neutral
Teres- 90 abd, 90 ER
du scap- lift off, bear hug, belly press. All high sp, low sn
Impingement tests
Neer- sp= 53%, sn= 79%, +LR= 1.76, -LR= 12.5
Hawkins- sp= 59%, sn= 79%, +LR= 1.63, -LR= 19.95
Yocum
Empty can- +LR= 3.9, -LR= .5
Instability tests and grades
Humeral head translation:
- anterior drawer 7.8 mm: 0-30= sup lig, 30-60= middle lig, 90= inf lig
- posterior drawer 7.9 mm: at 90
- sulcus sign indicates multidirectional instability, assess integrity of sup gh lig and coracohumeral lig- 10mm trans
- grades: 1= within glenoid, 2= over glenoid with spontaneous return, but no sx indicates laxity in jt, 3= over glenoid with no return.
- subluxation relocation test +LR=10.4-67, -LR= .2-.33
- apprehension +LR= 20.2-53, -LR= .29-.47
- suprise +LR= 58.6, -LR= .37
- Breighton scale
Labral tears types and location
Transverse, longitudinal, flap, horizontal cleavage, and fibrillated tears
60% ant sup
18% Post sup
1% ant inf
Labral tests
Clunk test Circumduction test Compression rotation- sp .24-.26/ sn= .76-.98 Crank test O'brien test- sp= .47-.99/sn= .11-.98 Memorial test Biceps load 2- sn= .90/sp= .97 Passive distraction test- sn=.53/sp= .94 ER supination test Jerk test- sn= .73/sp=.98 Kim test- sn=.80/sp= .94
Bankart versus SLAP
Bankart- up to 85% of dislocations, btwn 2-6 o’clock
SLAP- 10-2 o’clock
Four main types:
1) partial, fraying, not completely detached
2) labrum completely torn off glenoid (a,b,c)
3) bucket handle
4) tear extends along biceps tendon
ER/IR strength ratio
66%
Functional ratio
Eccentric ER to concentric IR ratio
Specific to the throwing shoulder
Adhesive capsulitis indicators
Pain at least 1 mo Sleep disturbances Inability to lie of affected shoulder All PROM restricted At least 50% reduction in ER rom
Primary versus secondary adhesive capsulitis
Primary: idiopathic
Secondary:
1) systemic- hx dm or thyroid
2) extrinsic- pathology not directly related to shoulder
3) intrinsic-known gh pathology NOT sp surgery
3 stages of primary impingement
1) edema and hemorrhage, young, (+) impinge mtn sign, painful arc, mm weakness
2) fibrosis and tendonitis, 25-40 yrs, (+) above
3) bone spurs and rupture,
Secondary impingement
Underlying instability of gh joint
Reasons for rtc pathology
Primary and secondary impingement
Tensile overload
Macrotraumatic failure
Posterior impingement
% rtc tendon damage to result in weakness
30%
Posterior impingement position
90/90 for infra and supra due to ant translation
Most stress on articulate portion of supra and infra with horozontal abduction btwn what range?
30-45
Much less at scapular and 15
Position to best stretch post capsule
30 elevation in scapular plane
Jobe isotonic rtc exercises
S/L ER AND PRONE SHOULDER EXTENSION
prone horizontal abduction and 90/90 ER
Importance Bolster with ER TE
10% increase infraspinatus
Decrease “wringing out” of supra
Increase in subacromial space
% max effort ideal to isolate rtc
40%
Rtc best able to maintain gh stability at what angle?
29.3 ant to coronal plane
Rtc tear size classification
Small < 1cm
Medium 2-3 cm
Large 3-5 cm
Massive >5cm
After rtc repair early prom
In scap plane to minimize tensile loads through tendons
Surgical options for shoulder instability
Arthroscopic capsular plication, inferior capsulear shift, inferior capsulolabral repairs, and Bankart repair
Surgical intervention for different forms of superior labrum anterior posterior lesions
Type one: debridement
Type two: biceps anchor attachment
Type III: debridement of Bucket handle type tear
Type four: same as three; biceps anchor repair, biceps tenodesis
Status post slap repair external rotation range of motion progression
Over the first four weeks increased 10° per week without exceeding 30°
Early extra rotation performed in 45° or less of abduction
Extra rotation with 90° abduction not recommended until six weeks
As long as motion is progressing forceful attempts to gain full range of motion are not needed
AC joint separation classifications
Type one: sprain without tear
Type two: rupture of AC capsule and ligaments without injury to cc ligaments
Type III: complete rupture of AC And cc ligaments in an increased cc distance
Type 4–6: rupture of (AC) NCC ligaments and varying degrees of soft tissue trauma in greater clavicular displacement
For mean surgical options for AC joint reconstruction
1: primary fixation with or without ligament repair
2: primary fixation at the cc interval with or without AC ligament repair/reconstruction
3: distal clavicle excision with their without cc ligament repair or coracoacromial ligament transfer
4: muscle transfer with her without distal clavicle excision of
Frozen shoulder and corticosteroid injections recommendation level
A level for corticosteroid injections combined with shoulder mobility and stretching exercises.
Recommendation level for patient education for patient with frozen shoulder
B: describe natural course of disease, promote activity modification to encourage functional pain-free range of motion, match the intensity of stretching of the paints patient’s current level of irritability
Recommendation level for the treatment of frozen shoulder with modalities
C: Diathermy ultrasound or electrical stimulation combined with mobility and stretching exercises to reduce pain and improve shoulder range of motion in patients with adhesive capsulitis
Recommendation level for joint mobilization for the treatment of frozen shoulder
C: joint mobilization procedures primarily directed to the glenohumeral joint to reduce pain and increased motion and function in patients with that he’s of capsulitis
Recommendation level for stretching exercises for the treatment of frozen shoulder
B: instruct patients with it he’s of capsulitis in stretching exercises. The intensity of the exercise should be determined by the patients tissue irritability levels
Frozen shoulder irritability classification
HIGH irritability: pain greater than 7/10 Constant night or resting pain high disability pain prior to end of range of motion active range of motion less than passive range of motion MODERATE irritability: Pain number 4–6\10 Intermittent night or resting pain Moderate disability Pain at and range of motion Active range of motion equal to passive range of motion SLOW your ability Pain less than 3/10 No resting or night pain Low disability Minimal pain at and range Active range of motion equal to passive range motion
Expected flexion rom outcomes status post TSA for pathology (OA,RA, Fx, rtc)
Osteoarthritis: elevation 131- 145°
Rheumatoid arthritis elevation: 103°
acute fractures: 93–128°
Cuff deficient arthritis: 86–120°
S/p repair exercise in what plane and why?
Scapular
Ant joint lax
Joint congruency
ROM limitation following HA for acute PHF fx.
50 deg
