Shoulder Flashcards
head of humerus faces
med, post, lat
axis of head of humerus forms angle
130-150 degrees
head of humerus angled post
30-40 degrees
post capsule
under tension when shoulder in flexion, adduction, and/or IR
sup GH ligament
under tension when shoulder in adduction, inf and post translation of humerus
middle GH lig
under tension with shoulder in ER, rests ant translation
Inf GH lig 3 parts
ant taut when shoulder abducted, ext, and or ER
post taut when shoulder IR and or abducted
axillary pouch taut in 90 flex
primary restraint against ant and post dislocated
coracohumeral ligament
post band limits ER and flex of GH and inf and post translation humeral had
ant band limits ER and ext of GH and inf and post translation humeral head
suprahumeral space width
9-15 mm
suprahumeral space boundaries
inf- tuberosity of humeral head
anteromedial- coracoid process
sup- coracoacromial arch (accordion process, coracoacromial lit, coracoid process)
suprahumeral space contents
long head of biceps tendon sup joint capsule supraspinatus upper margins subscapularis and infraspinatus subacromial bursa
type 1 acromion
flat
type 2 acromion
normal
type 3 acromion
curved, more problematic, causes impingement
GH joint open packed
55 degrees abd, 30 degrees horizontal adduction, neutral rotation
GH closed packed position
full abduction, full external rotation
GH capsular pattern
ER limited more then abduction, limited more than IR, limited more than flexion
ER>ABD>IR>Flex
AC Joint must rotate ? for full elevation
40-50 degrees
coracoid clavicular ligament tense during
arm elevation resulting in post rotation at SC joint
AC joint open packed position
arm by the side
AC joint closed pack position
90 degrees GH abduction
AC joint capsular pattern
pain at extremities of ROM, especially horizontal adduction and full elevation
Sternoclavicular joint open packed position
arm by side
SC closed pack
max arm elevation and protraction
SC capsular pattern
pain at extremes ranges of motion, especially full arm elevation and horizontal adduction
during full arm elevation, scapular should have ? ER, ? UR, ? post tilt
15-25 ER, 60 UR, 15-30 post tilt
scapulothoroacic open pack position
arm by side
scapula in average 30-45 degrees IR, slight UR, 5-20 degrees ant tilt
scapulothoracic mechanics during full arm elevation
60 UR
15-30 post tipping
15-25 ER
Biomechanics of elevation 0-90
supraspinatus contracts to initiate abduction
remaining RC contract to pull humeral head into glenoid fossa
around 20-30 degrees, scapular upward rotation begins with concurrent clavicular elevation and axial rotation
at 90 degrees, upper extreme of GH abduction is reached and clavicular elevation creases due to tension of costoclavicular ligament
at this point the scapular has rotated upwardly around 30 degrees
biomechanics of elevation 90-150
scapula UR 60 degrees with scapular contribution peaking between 90-140 degrees
120 humeral elevation
75 degrees of GH ER needed
UR accompanied at SC and AC by 30-40 degrees of post clavicular axial rotation and clavicular elevation of 30-36
biomechanics of elevation 150-180
abduction beyond 150 requires adequate motion of upper thorax and cervical spine, while bilateral abduction requires thoracic ext and increase in lumbar lordosis
strengthening should be preformed in ? plane
scapular
adhesive capsulitis
frozen shoulder restriction in active and passive ROM female >40 trauma diabetes prolonged immobolization thyroid stoke or MI autoimmune follows capsular pattern can take 1-3 years to resolve
adhesive capsulitis stages of progression
- mild signs and symptoms
adhesive capsulitis intervention per stage
- determine degree of inflammation and irritability
1. actue- relieve pain and gentle stretch to capsule - low grade mob, pendulum exercises, passive stretching upper trap and levator scapulae, postural awareness
2. subacute- more agressive ROM exercises, strengthening with isometrics then concentric
3. stages 3 and 4- grade IV mob, low load long duration stretching
glenohumeral instability continuum
- instability- abnormal symptomatic motion of the Gh joint that affects normal joint kinematics and results in pain, subluxation, or dislocation
- subluxation- joint contact lost but capsule not necessarily torn, might just be stretched, UE paralysis, multiple dislocations
- dislocation- complete separation of the joint surfaces, usually ANT, concern axillary N injury
how is glenohumeral instability classified?
frequency
magnitude/degree
direction
origin
bankhart lesion
GH instability avulsion of the ant info labrum from the glenoid rim, occurs in lower part of labrum inf GH ligament torn tighten ant capsule loss of 12 degrees of ER post procedure
Hill Sachs lesion
GH instability
compression fracture of the post humeral head at the site where the humeral head impacted the info glenoid rim
GH instability history
most common complaint is pain often result of trauma repetitive microtrauma joint laxity ant instability (98%) pain with over head movements symptoms occurs in abduction and ER position
GH instability examination
ROM may be excessive (hyperbole) patient may self limit provocative positions (ER and abd) transient neuro symptoms easy fatiguability special tests: provacative apprehension test/relocation load and shift sulcus sign
GH instability intervention
functionally stabilize shoulder -scap stability -rotator cuff musculature -neuromuscular control work from stable to unstable positions closed chain activation in early rehab activity modifications
GIRD
glenohumeral internal rotation deficiency
loss of IR (
SLAP lesion
sup labrum lesions that are both ant and post
sup portion of biceps pulls sup labrum away creating bucket handle lesion
SLAP lesion history
single traumatic event to repetitive micro trauma FOOSH forceful biceps contraction pain with overhead activities NOT painful at REST catching or locking in joint
SLAP lesion examination tests
O Briens
clunk/crank
yergasons
load and shift test
AC joint sprain
one of the most frequently injured joints
acute- fall onto shoulder with arm ADDUCTED at side
chronic-OA, inflammatory arthritis, mechanical problems
usually involved dislocation
6 types of AC joint sprain
1- tenderness and mild pain
2-slight visual change in acromion/clavicle, if displaced acromion
3- obvious gap between acromion and clavicle, inf displaced acromion
4- clavicle displaced posteriorly
5- large distance between clavicle and coracoid process, inf displacement acromion
6- often associated fracture of clavicle and upper ribs and injury brachial plexus
AC joint sprain examination
localized pain step off deformity pain at end range motions crossover test 1- pain with resisted adduction 2- pain with resisted adduction and abduction 3- all active motions painful, esp ABDUCTION immobilization 1,2,3 surgery for 4, 5, 6 bc displaced
rotator cuff pathology
50-70 % shoulder issues
SUPRASPINATUS most often affected (LOW blood supply)
injury mechanism: compression-reduction size subacromial space, tensile overload-throwing, hammering
macrotrauma
tendonitis- supra followed by infra
tears- more common in men than women
RC history
pain, weakness, loss of ROM
dull ache worse after activity, sleep on affected arm, reaching, putting on coat
loss of function, can’t hold arm out (tear)
tendonitis- better after 3 weeks, full AROM and PROM but painful, DEEP FRICTION massage
tear- pop at injury, sudden onset, not better after 3 weeks
higher humerus, palpable defect at gr tuberosity, muscle atrophy, reverse scap humeral rhythm
RC exam
painful arc- mid range elevation pain b/c tissues most activated (supraspinatus pain most evident during abduction or caption 50-130 degrees)
resisted motion:
supraspinatus- pain with abduction and ER
infraspinatus- pain with ER
complete tear- positive drop arm test
partial tear-positive supraspinatus test
list off test- biceps tendon, subscapularis
ER lag- supraspinatus or infra
muscle contractile injuries painful when
passively stretched and actively shortened
subacromal impingement syndrome
increase in sup translation of humeral head results in decrease space in coracoacromial arch
intervention- isometrics-closed-open, RC strengthen, scapulothoracic
Primary SIS
primary-ANT impingement, intrinsic degenerative process in the structures occupying the subacromial space, mechanical encroachment, >40 yo, may be hypomobile
limited horizontal abduction, limited IR, post cap tightness, pain with over head activity
Secondary SIS
secondary- CORACOID impingement, lesser tuberosity of the humerus encroaches on the coracoid process (alters PICR, humerus migrates too sup), hyper mobility, instability
limited IR, excessive ER
shoulder arthritis
humeral head migrating sup or history of trauma can accelerate degenerative changes loss of ROM and strength capsular pattern compression/sleeping can cause pain AC joint most commonly affected
shoulder surgical options
TSA-replace glenoid fossa and head of the humerus
hemiarthroplasty-replace head of humerus
reverse total shoulder- invert prothesis so ball is on the scapula and concavity is on the humerus (when RC not salvageable)
subacromial bursitis
where friction between bone and tendon is typical
excessive friction can lead to inflammation
3 types: activity/trauma, calcified, infectious
can be seen with autoimmune disease
rubbing will make it worse
iontophoresis can help calcifications
bursitis history/exam
may or may not have MOI
aching over deltoid region
rapid onset with activity
pain reproduced with passive abduction at 180, passive IR, passive horizontal adduction (may feel empty end feel)
acute-may not be able to reach overhead
noncapsular pattern
palpation distal to AC joint with shoulder held in extension
if a pt has always been able to reach overhead without restriction (even with pain) it is more suggestive of…
tendonitis
clavicle fracture
MOST COMMONLY fractured bone in CHILDHOOD
usually from FOOSH, a fall or blow to shoulder or direct blow
difficulty elevating the arm >60 degrees
painful horizontal adduction
deformity
proximal humerus fx
direct blow to ant, lat, or postlat, FOOSH, osteoporosis, common site of metastasis of LUNG
brachial plexus injury
entrapment from cervical rib stretch injury radiation clavicular fx compression by soft tissue
TOS
involved brachial plexus and subclavian artery
compression of tight muscles
tingling in arm after carrying heavy objects
tight scalenes
peripheral nerve injuries
axillary-decreased abduction strength
decreased ER and elbow ext strength
varying loss of sensation
reflex sympathetic dystrophy
complex regional pain syndrome
pain out of proportion, cold clammy limbs,trauma,distal first
night pain
psychologicaal disturbances
discoloration
chronic edema
1- burning pain, tenderness, swelling, vasomotor changes
2- persistent aching, swelling w/ hardening. skin/nail bed changed
3- skin and subcutaneous atrophy, development contractures
