Shoulder Flashcards
Dx pearls based on patient reports
Dec. Neck ROM suggests C/S assessment
Arms Slips suggests instability
Pain overhead suggests impingement
Altered ROM but no associated pain suggests RTC pathology or neuropathy
Heaviness after activity suggests vascular
R Shoulder Pain referral (non-MSK)
Liver
Stomach
Pancreas
Pancoast Tumor (apex of R lung)
L Shoulder pain referral (non-MSK)
Heart
Spleen
Normal mechanics for overhead elevation require scapula to perform what?
Upward rotation and posterior tilt
- Dec. rotation in RTC pathology, impingement, instability’
- Excess upward rotation and anterior tilt in Ad. capsulitis
Weak Serratus
Winged scapula with dec. Up.Rot. and Post. Tilt
*C5,C6,C7 nerve injury to Long Thoracic nerve possible
Hypertonic Upper Trap
Increased clavicular elevation
Hypertonic Pec. Minor
Inc. scapula IR and Ant. Tilt
Post. Capsule tightness
Inc. Scapula Ant. Tilt
Kyphotic Posture
Inc. IR and Ant. Tilt of the scapula with Dec. Up.Rot.
What is GIRD?
GH IR deficiency present in athletes with inc. ER, dec. IR
Measured with stable scap at 90/90
Tight Post. capsule with humeral retroversion causes anterior translation of the humeral head
*Can cause impingement related to weak SA, MT, LT with hypertonic UT
What is SICK scapula?
(S)capula malposition
(I)nferomedial border prominence
(C)oracoid pain/malposition
dys(K)inesis of movement
*Primarily affects overhead athlete
Dropped scapula on involved side with:
Tight Pec. Minor and possibly LS, Lats., Rhomboids
Shortened biceps
Scapular Exercises
Best for LT: Low Row, Robbery
Best for SA: Lawn Mower, Lower Row, Robbery, isometric Inf. glide
*Inc. LT activation also present in push-up with opposite hip Ext.
Low Row with opposite SLS increases recruitment of LT vs. UT
Dec. Hip IR in opposite LE
Inc. Lordosis (Tight Lats?)
SICK scapula DDx
Ant. coracoid pain can be confused with instability
(+)Impingement and subacromial pain due to biomechancis
AC joint pain from anterior tilt position
TOS (clavicle position)
Types of dyskinesia in overhead athletes
Ant. Tilt - prominence of inferomedial border, Labral involvement
IR - prominence of medial scapular border, Labral involvement
Down.Rot - prominence of superomedial border, Impingement/RTC pathology
Shoulder screening for pathology with ER vs. IR (IRRST)
ER painful or weaker than IR (RTC pathology)
IR weaker vs. ER (labrum involvement)
No difference B/T ER and IR (Extra-articular)
LHB, AC joint, Referred pain
Tests for RTC pathology
Dropping sign is best to R/O infraspinatus
(Cluster) HK, painful arc, infra MMT is good to rule in impingement and/or RTC pathology
ERLS good to R/I tear of Supra/Infra
IRLS good to R/I and R/O Subscap
Resisted IR good to R/I Subscap
RTC pathology cluster (3/3)
HK (resisted ER/Flx in 90 degrees and IR position) Infra MMT (resist ER with wrist against stomach) Painful Arc (pain B/T 60-120 degrees in scapular plane)
SS tendinopathy cluster to rule in pathology (3/3)
Age >65
Infra MMT
Night Pain
*ERLS is a better test
Tests for Anterior Instability
Apprehension (R/I) BEST
Ant. Release (R/I and R/O) BEST
Apprehension & Relocation (R/I and R/O)
Tests for SLAP
Biceps load I/II (R/I and R/O) BEST
Passive distraction, Active compression (R/I and R/O)
Posterior Impingement/Labral Tests
Kim Test (R/I and R/O) Jerk Test (R/I and R/O)
Posterior Impingement test (R/O posterior impingement)
AC joint (test cluster to R/I)
Crossbody ADDuction
O’brien’s
AC resisted extension
Upper Cross Syndrome
Shortened: UT, LS, SCM and Pec. Minor
Weak: SA, Rhomboids, LT, DNF
Primary Impingement
Caused by Abnormal relationship between the RTC and coracoacromial arch (Type 3 Acromion)
Age > 40
Unable to sleep on involved side
Ant. and upper lateral arm pain
Secondary Impingement
Dec. in subacromial joint space (caused by instability) Biomechanical Younger patients, overhead athletes "Dead Arm" SICK scapula
Posterior Impingement (undersurface impingement)
ABD+ER (Cocking phase of throwing)
Associated with anterior instability
RTC tendinopathy rehabilitation
IR ROM deficits common
- FF AROM causes SAI
- ER AROM @90 causes internal impingement
ER strength deficits common followed by supraspinatus
*Strength deficits magnified by poor scapular position in protraction
SLAP tear classification
Type 1 - Labrum frayed, biceps intact
Type 2 - Biceps anchor pulled away
Type 3 - Bucked Handle, biceps intact
Type 4 - Bucket Handle with biceps tear
*Types 2 and 4 require repair of biceps
Cuff Repair Types
Arthroscopic - weaker fixation
Mini-Open - Allows for early deltoid AROM
Open - 6-8 weeks restriction of deltoid AROM
RTC Tear classification
Small 5cm
GH Laxity grading
Normal - mild translation
Grade 1 - Feel GH ride up to glenoid 25-50%
Grade 2 - GH overrides glenoid but reduces
Grade 3 - GH overrides glenoids but no reduction
Shoulder instability classification (FEDS)
Frequency (episodes in last year?)
Etiology (Traumatic?)
Direction (which way did it go out?)
Severity (needed help to ‘pop’ it back in?)
Presentation of shoulder dislocation
Arm held at side and painful, prominent acromion
*Axillary nerve regularly involved so there is weakness in the T. Minor and Deltoid (Anterior Dislocation)
Shoulder Dislocation clinical exam
Load/Shift test
Apprehension/Relocation
Sulcus sign (>2 cm vs. uninvolved is clinically significant)
Shoulder XR to perform after reduction to R/O other lesions
Scapular A/P (Glenoid fx)
Striker Notch (Hill-Sachs)
Westpoint Mod. Axillary view (IGHL avulsion, Bony Bankart, Ant.Inf. Glenoid insufficiency)
Labrum radiological exam
MRI with contrast, hemarthtrosis serves as contrast in acute injuries
Prox. humerus fracture
85% minimally displaced
Benefit from early scapular ROM
GH joint mobilization as early as 2 weeks to restore normal elevation by 27 days (1 month)
*Immobilization longer than 3 weeks is of NO benefit
Calcific Tenonitis recommendations
R/O non-MSK conditions by timeframe which usually resolves in 1 week with NSAIDS
Benefit from high dose U/S (20+ visits at 3.3 mhz)
Frozen Shoulder
Predictors:
Age 40-65
ER or IR limited above 90 deg
Passive ER limited with ADDuction
*(R/O if PROM normal)
Will usually resolve by 12-18 months
Shoulder Functional Outcomes for Ad. Capsulitis
DASH
ASES
SPADI
Adhesive Capsulitis
Early intra-articular injection recommended if highly irritable and painful in acute phase (0-3 months)
Stages of Adhesive capsulitis
Stage 1 (0-3 months) (pain with A/PROM)
Stage 2 (3-9 months) FREEZING (significant ROM restriction)
Stage 3 (9-15 months) FROZEN (pain only at end range)
Stage 4 (15-24 months) THAWING
Treatment of Impingement with T/S HVLA (3+/5)
Symptoms
Radiology for Labral teat
MRA is best but arthroscopy is the gold standard
ROM goals for RTC and Labral Repairs
Full ROM expected by 10-12 weeks
ROM precautions for TSA and RTSA
TSA: excessive ER should be avoid (more than 45 degrees in first 6 weeks can indicate a possible subscap tear)
RTSA: Avoid ADDuction/IR/Extension
Test for Subscap. tendinopathy or tear
IRLS BEST to R/I and R/O tear
Lift Off (better) and Resisted IR tests are best for diagnosing a tendinopathy
