Shoulder Flashcards by Colin Gundling

Scapula position on thorax

Sup at second thoracic vert
Inf at seventh thoracic vert
30-45 set in coronal plane

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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

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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

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Supraspinatus role in rtc force couple

Counteract deltoid and approximate gunmetal head

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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

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Mech of secondary impingement

Above 90 rhythm relies on sa, lt, mt which have decreased levels of firing

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Ant/post rtc force couple

Results in inf dynamic stability and concavity-compression mechanism

Mid range of elevation

Deficts common in throwing athletes

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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

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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

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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)

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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.

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Throwing phase peak stress on external rotators

At Follow through phase

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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

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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

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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

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Labral tears types and location

Transverse, longitudinal, flap, horizontal cleavage, and fibrillated tears

60% ant sup
18% Post sup
1% ant inf

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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

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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

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ER/IR strength ratio

66%

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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