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Extremity Adjusting > Shoulder > Flashcards

Shoulder Flashcards

1
Q

Pain point for extremities is usually ___________, while for vertebral subluxations, it is usually over _____

A

Extremities = right over the joint

VS = over an area

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2
Q

Joints of the shoulder

A

Anywhere from 4-7

1) Sternal-Clavicular
2) Acromio-clavicular
3) Glenohumeral
4) Scapulo-Thoracic

(Sometimes first rib and coracoid)

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3
Q

Extremity Analysis Protocol

A

1) History
2) Visualization and Static Palpation
3) Active ROM
4) Passive ROM
5) Orthopedic Test(s)
6) Muscle Test(s)
7) Fluid motion
8) X-rays
9) Traction Type Adjusting procedures
10) Thrusting Type Adjusting procedures

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4
Q

Shoulder Orthopedic Tests

A
  • Dawburns’
  • Dugas
  • Yergason’s
  • Drop Arm
  • Shoulder Apprehension
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5
Q

T/F The acute case history will give up to 80% of the information needed to formulate a working Dx. Chronic cases are usually not helpful except in telling the Dr. where the pain is

A

True

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6
Q

Shoulder ROMs

A
  • Flexion = 180
  • Extension = 50
  • Abduction = 180
  • Adduction = 50
  • Internal Rotation = 90
  • External Rotation = 90
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7
Q

Scapulo-Humeral Ratio

-How do we determine this ratio?

A

Average is 2:1

  • Humerus should move around 120 degrees
  • Scapula should move around 60 degrees

120/60 = 2:1

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8
Q

On the average healthy patient, the first 90-120 degrees of ROM in abduction will come from the ___ joint with the ____ being stabilized by the _____ muscles

A

G-H joint
Scapula
Serratus muscles

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9
Q

If the scapula begins to move in the first 30 degrees of abduction and over all S-H ratio is 1-1 with the patient having 120 degrees of ROM overall. What would we suspect?

A

Dysfunction of the G-H joint

-Further examination is needed

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10
Q

If we noted a 4:1 S-H ration with full ROM on abduction, it would indicate a ________

A

Loss of function at the Scapula

-Could be contributed to S-T, St-Cl, or A-C joint dysfunction and further examination would be needed

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11
Q

Appley’s Scratch ROM studies (all 3 parts)

A

3 parts = adduction, external rotation, and internal rotation parts

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12
Q

Patient demonstrates all 3 parts of Appley’s Scratch. What would the misalignment be if the patient had:

1) decreased adduction
2) decreased external rotation
3) decreased internal rotation

A

1) S-T medial
2) S-T medial and G-H inferior
3) S-T lateral and G-H posterior

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13
Q

What is the most common direction for St-Cl to occur?

A

Superior (List as St-Cl S)

  • St-Cl should be level from side to side at the proximal end
  • X-ray findings will show the line drawn across the top of the proximal ends broken
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14
Q

St-Cl S

  • Pain is usually over the _____
  • Loss of ROM and ____ may be noted
  • If the proximal clavicle dislocation, it will usually go _________
A
  • Pain over the joint space
  • Loss of ROM and Crepitus
  • Dislocates anterior and inferior
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15
Q

St-Cl Muscle Test

A

Pectoralis Major

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16
Q

What are the St-Cl listings?

A

St-Cl Traction Seated
St-Cl Traction Supine
St-Cl S

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17
Q

A-C Evaluation

  • History is usually _____
  • Most common direction of subluxation is _______
  • Pain is usually _______
A
  • Unknown by the patient
  • MC direction is posterior and superior
  • Pain is usually right over the joint.
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18
Q

Muscle test for the A-C evaluation

A

Coraco-brachialis

-looking for weakness

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19
Q

Visualization for the A-C joint

A

Distal end of the clavicle is slightly more prominent than the surrounding structures.

  • The transition from the trapezius across the acromion process should be smooth.
  • When subluxated you will see a bump (compare side to side)
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20
Q

Motion checks for the A-C joint

A
  • May find loss of abduction
  • Loss of scapular portion of S-H ratio
  • Loss of fluid motion while stabilzing the humerus and scapula and depressing the distal end of the clavicle form S to I
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21
Q

What history would make you think the patient suffered a A-C separation?

A

-Falling on the outstretched hand (FOOSH)
-Car accidents where the steering wheel hits under the clavicle
-Stepping off a step ladder while hanging on with one hand
(almost always with the arm in abduction)

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22
Q

X-ray findings for A-C separations?

A

Distance between a line drawn along the bottom of the clavicle and another along the top of the coracoid process have more than 1.3 cm between them

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23
Q

Slight tear of the conoid and trapezoid ligaments

  • No horizon sign (bump like subluxation, not a step)
  • Coraco-brachialis muscle test weak
  • Pain over the joint
  • Excess fluid motion and X-ray lines over 1.3 cm
A

Grade 1 Separation A-C joint

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24
Q
  • Horizon Sign + (step defect seen)
  • Coraco-brachialis muscle test weak with clavicle moving down.
  • Excess fluid motion.
  • Pain over joint severe.
  • X-ray line analysis shows measurement over 1.3 cm
A

Grade 2 Separation A-C joint

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25
Q
  • Complete tear of the conoid and trapezoid ligaments
  • Horizon sign (step defect seen)
  • Coraco-brachialis muscle test weak without movement of the clavicle during challenge
  • Fluid motion excessive
  • X-ray lines over 1.3 cm measurement
A

Grade 3 Separation A-C joint

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26
Q

A-C Listings

A

AC PS

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27
Q

Scar tissue built up in the capsule of the G-H joint

  • Presents in the acute stage after exacerbating a chronic problem
  • Pain and loss of function do not correspond with severity of trauma in most cases
A

Frozen shoulder

-a.k.a. Adhesive Capsulitis

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28
Q

Evaluation for frozen shoulder

A
  • Loss of active AND passive ROM in all ranges at the G-H joint, but normal to excessive motion in the S-T joint
  • Need to rule out other shoulder limiting pathologies
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29
Q

Care for frozen shoulder

A

Starting with finding a comfortable position and supporting the patients arm in this position while applying ice until the patient can tolerate traction.
-May take days or a week

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30
Q

3 part procedure for frozen shoulder care

A

1) Traction and release in the neutral position taking care to stay within the patient’s pain tolerance
2) Traction and move through ROM gained within pain tolerance
3) Repeat part 2 until we are no longer making progress and then add an impulse from S-I at the end of ROM (longitudinal to the patients humerus)

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31
Q

For frozen shoulder care, we have done part 2 and no more progress is being made between visits. What do we do next?

A

Go to part 3 and apply one impulse at each ROM until we have a post check of more motion of hear a release

(continue with part 2 until progress is not being made)

32
Q

What is the home care instructions for frozen shoulder?

A

Have patient do ROM exercises each day at home such as:

  • Appley’s Scratch exercise
  • Wall walking exercise
  • Weighted traction exercise
33
Q

The G-H joint is held in it’s proper position by the ________, especially when in the upright posture. This makes the area ____ to heal with injured

A

Held by the surrounding musculature

-SLOW to heal because of partial ischemia at any given moment (gravity also works against the joint in weight-bearing)

34
Q

What acts to depress the humerus during abduction?

A

Rotator Cuff

35
Q

The thin and weak anterior capsule is susceptible to tears and dislocations. What helps to protect the anterior capsule?

A
  • Glenoid labrum

- 3 glenohumeral ligaments (superior, middle, inferior)

36
Q

G-H History

  • Many time the patients reports _______
  • Usually the G-H joint subluxates _______ and dislocates ____________
  • Dislocation is usually caused by a ________ mechanism
A
  • Reports they don’t know how it happened
  • G-H subluxates inferiorly and dislocates anterior and inferior
  • Usually dislocates from a FOOSH mechanism
37
Q

T/F 90% of dislocations of the G-H joint are anterior dislocations

A

True

  • Mechanism is usually forced abduction and external rotation causing the joint capsule to be wound tight (closed pack position)
  • FOOSH
38
Q

Physical signs of an anterior G-H dislocation

A
  • Severe pain over the G-H joint
  • Prominence of Acromion process (loss of roundness of the shoulder)
  • Opposite arm supports the affected arm in abduction and external rotation

(X-ray pre and post reduction to rule out fractures)

39
Q

Complications of G-H anterior dislocations

A
  • Anterior labrum, capsule, and supraspinatus tear
  • Avulsion of the greater tuberosity
  • Nerve injury 33% of the time (50% if >50)
  • Axillary blood vessels damage or occlusion
40
Q

Location for 85% of anterior G-H dislocations

A

Subcoracoid

Could also be subclavicular, subglenoid (arm may be held in complete abduction), or posterior (subspinous)

41
Q

Rate the different shoulder reduction technique in order from best to worst

A

1) Fares (Pain = 1.57/10; Time =2.36 minutes; Success = 87%)
2) Hippocratic (Pain = 4.88/10; Time = 4.4 minutes; Success = 72.5%)
3) Kochers (Pain = 5.44/10; Time = 4.4 minutes; Success = 68%)

FOR ALL: once the shoulder has reduced, place into the Dugas position

42
Q

T/F If not treated within 20 minutes, shoulder dislocations may need anesthesia to be successful

A

True

43
Q

Post checks following shoulder reduction

A
  • X-ray
  • Vascular assessment (Allen’s)
  • Nervous
  • Musculo-skeletal
44
Q

Rehabilitation for dislocated shoulder

A
  • 3 weeks in a sling (minimize external rotation and abduction)
  • Exercise fingers and wrist 1st 3 weeks
  • 4th week begin exercises in internal rotation and adduction
  • After 6th week exercise in all ROM especially abduction and external rotation
45
Q

T/F The reoccurrence rate for shoulder dislocations if the first one occurs before 20 is 15%

A

FALSE

-Reoccurrence rate is 80-95% if first occurs before 20 years old

46
Q

What is the mechanism of injury for suffering a posterior G-H dislocation?

A

Posterior = 10% of all G-H dislocations

Mechanism is falling with the arm in internal rotation and adduction

47
Q

Physical signs of a posterior G-H dislocation

A
  • Patient presents with the arm held in internal rotation and adduction
  • Coracoid process is prominent
  • Humerus is palpated under the scapular spine
48
Q

Treatment for posterior G-H dislocations

A
  • Refer to hospital to be reduced under anesthesia
  • Cast after reduction (in external rotation)
  • High rate of fracture
49
Q

What is the history associated with G-H inferior?

A
  • Patient doing some lifting or carrying on a daily basis

- If traumatic, may show up only after healing process has taken place because muscles have guarded down and forward

50
Q

Evaluation for G-H inferior

A
  • Dimpling in the soft tissue over the superior G-H joint will be seen
  • Pain will be noted over the anterior portion of the G-H joint
  • Fluid motion is lost at all the G-H joint in all directions, but most noticeably from I to S
51
Q

ROM findings for G-H inferior

A
  • ROM is usually good
  • Losses may be noted on Appley’s in external rotation
  • Loss of humeral portion of S-H ration
  • Muscle strength loss when testing anterior deltoid
52
Q

DDx for G-H inferior

A

Anything causing pain or loss of function in the area

  • Cervical or thoracic subluxation
  • Bicepital tendonitis
  • Subacromial bursitis
  • Deltoid strain
  • Rotator cuff tear
  • G-H dislocation
  • Posterior humerus
  • A-C PS
  • Referred pain from organs (Gall Bladder or Heart)
  • Etc.
53
Q

History for G-H Posterior

A

Injury where the patient has trauma from A-P and guards against it with an outstretched arm and the elbow locked

54
Q

Evaluation for G-H Posterior

  • Visually _______
  • Pain point ______
  • Fluid motion ______
  • Muscle weakness ____
A
  • Visually normal
  • Pain point found over the posterior G-H articulation
  • Fluid motion is lost over all, but especially P-A direction
  • Muscle weakness found when testing Teres major
55
Q

ROM findings for G-H Posterior

A

Decreased ROM on internal rotation or extension as on Appley’s scratch behind the small of the back
-Decrease in the humeral portion of S-H ration

56
Q

G-H Procedures

A 
G-H Traction Supine
G-H Traction Seated
G-H I
G-H P Prone
G-H P Seated
57
Q

Muscular joint with no capsule and will normally be very freely movable

A

Scapulo-Thoracic joint

58
Q

What is the MC direction of misalignment for the S-T joint?

A

Medial or Lateral

in reference to the inferior tip

59
Q

What nerve and muscle are weak if someone is displaying a winged scapula? What exercise can strengthen this? Where should we look to adjust?

A

Long Thoracic Nerve controlling Serratus Anterior

  • Any exercise that causes Protraction of the scapula
  • Lower cervical/upper thoracic
60
Q

S-T L

  • History:_______
  • Pain:________
A
  • Hx: Someone who works above their head, or holds their arms up in their job such as carpenters, painters, hairdressers, (or people who work at computers stressed)
  • Pain: noted as a deep aching in the Subscapularis muscle (medial and lateral ache)
61
Q

Visualization for S-T L

A
  • Medial border of scapula is farther away form the spine

- Hunching/ rolling shoulders may be noted (puts lot of stress on the weak anterior inferior labrum)

62
Q

What ROM on Appley’s scratch will be most limited with S-T L?

A

Internal rotation

-Still need to DDx G-H P though

63
Q

T/F Will S-T L, the S-H ratio will show increased motion of the scapula with full abduction, and increased fluid motion from lateral to medial

A

FALSE

  • S-H ratio will be decreased motion of the scapula (full Abduction though)
  • Fluid motion of the scapula will be decreased from L to M
64
Q

S-T M

  • History:_______
  • Pain:_________
A
  • Hx: someone with midback pain usually of a chronic nature with rhomboid muscle guarding (rule out spinal subluxation first). Visualization may show a prominent chest due to guarding
  • Pain: Deep aching nature in the Subscapularis
65
Q

Visualization finding for S-T M

A
  • Medial border of the scapula will be closer to the spine than the opposite side
  • Normal = 3 fingers width from the spine (varies from patient to patient)
66
Q

ROM findings for S-T M

A
  • Appley’s scratch will be limited on external rotation and abduction
  • Abduction will be slightly limited
  • S-H Ration will show a diminished scapular motion
  • Fluid motion from M to L will be decreased
67
Q

S-T Listings

A

S-T M Side Lying
S-T M Prone
S-T L

68
Q

Which is NOT true for evaluating the ST-CO joints?

a) Usually very tight in their attachment to the sternum
b) Constantly subluxated or fixated
c) Adjusting the thoracic spine addresses rib problems
d) Pain in the intercostal area is usually associated with T-spine subluxations

A

b) Constantly subluxated or fixated

RARELY will be subluxated or fixated

69
Q

History for ST-CO problems

A
  • Patient had no idea what started the pain
  • Stepped on in sports or hitting the steering wheel in a car accident are traumatic examples
  • May see a little swelling over the joint on visualization
70
Q

DDx for ST-CO problems

A
  • Thoracic subluxation
  • Shingles (times of stress produces intercostal neuralgia)
  • Pneumonia
  • Cardiac arrest
  • Pleurisy
  • Etc.
71
Q

Pain findings for ST-CO problems

A
  • Found right over the involved joint
  • Superior subluxation = pain is above the joint in the intercostal space
  • Inferior subluxation = pain is found to be inferior to the involved joint
72
Q

Motion findings for St-Co S

A

Rib is stuck in the inspiration position so it doesn’t fall in expiration

73
Q

Motion findings for St-Co I

A

Rib fixated in the expiration position and will not rise on inspiration

74
Q

Muscle test for St-Co

A

Pectoralis major sternal attachment

-Pull down instead of down and out (thats clavicular portion of pec major)

75
Q

St-Co Listings

A
  • St-Co Traction seated
  • St-Co Traction supine
  • St-Co S
  • St-Co I
76
Q

Muscle Test Review

1) St-Cl _______
2) St-Co _______
3) A-C ______
4) G-H I ______
5) G-H P _____

A

1) Pec major clavicular attachment
2) Pec major sternal attachment
3) Coracobrachialis
4) Anterior deltoid
5) Teres major

Extremity Adjusting (5 decks)

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