Shoulder Flashcards
signs of suprascapular nerve impingement
- scalloping over infraspinous fossa
- impingement at suprascapular notch (supraspin and infraspin weakness) and spinoglenoid notch (infraspin only), paralabral cyst formation common in ppl c superior labral lesions
- occasional numbness at lateral shoulder
suprascapular nerve - roots, muscles, sensory
C5-C6
supraspin, infraspin
lateral shoulder sensation in a small % of ppl
flip sign
resisted ER leads to medial border lifting
MMT for supraspinatus
scaption to 90 deg (full or empty can)
MMT for infraspinatus
IR of 45 deg
MMT of teres minor
90 deg scaption, 90 deg ER
MMT of subscapularis
HBB
muscles that get cut for TSA
deltopectoral approach:
- deltoid retracted laterally
- subscap release with tendon incision or osteotomy,
- regional capsule release,
- upper 1-1.5cm of pectoralis major tendon may be released (for greater exposure or IR contracture)
where does the humerus get cut for TSA
anatomical neck with 30 deg retroversion
what happens to the glenoid in a HA
left unaltered if appropriate version, otherwise concentric reaming may be needed to normalize
what happens to the glenoid in a TSA?
glenoid resurfacing with polyethylene component
what happens to the LH biceps tendon
tenodesed or tenotomy
tissue balancing during TSA
- humeral head should sublux 50% posteriorly
- subscap should allow min of 30-40 deg ER
- sometimes posterior capsule shift (tightening) is needed
average elevation of the sh after TSA? after HA? With RA?
TSA 131-145
HA 117
RA103-119
which provides better outcomes: TSA or HA?
TSA
what percent of ppl with OA have RCT
9% but there is mod to severe fatty degeneration of infraspinatus. lower scores and elevation with subscap fatty degeneration.
what does a biceps tenodesis usually help with with a TSA?
pain relief
what percent of ppl with RA have a full thickness RCT?
24-30%
elevation following HA following fx
ER
IR
average 100
15-24
L4-L1
precautions following HA following fx
avoid too much passive ER (50 deg) can disrupt fx healing
incidence of nerve lesions following proximal humerus fx
67%
axillary n most common
progression of HA if greater tuberosity is spared vs if osteotomy is required
AROM 6 wks
Strengthening 12 wks
osteotomy: AROM 12 wks
osteonecrosis is associated with which conditions?
fractures, steroid use, alcohol, cushing disease
bursal side (superior) RC tears are the result of
subacromial impingement
primary and secondary compressive disease
partial thickness tears on the undersurface of the articular side of the RC are associated with:
which pts:
tensile loads and GHJ instability
throwing athletes with anterior instability, capsular/labral insufficiency
size of small tear:
medium tear:
large tear:
massive tear:
small <1cm
medium 1-3cm
large 3-5cm
massive >5
following RC tear of supraspinatus, early ER and IR PROM is performed in which plane
scapular to dec tensile load in repaired tendon
effect of cross arm adduction at 60 deg elevation
no inc in strain at the supra or infraspinatus
pulley vs supine flexion activities in supraspinatus activation
greater in pulley
RC activation during codman - can this be passive?
minimal activity but not passive
codman with weight in hand
could increase anterior translation but no change in RC activation
rehab following RC repair - first 2-4 weeks
passive and minimally active or active assisted exercises
dislocation means:
subluxation means:
- complete separation of the articular surfaces
- excessive translation of humeral head on glenoid in association with sxs, not a complete separation
define instability
excessive symptomatic translation of the humeral head relative to the glenoid when stress is applied
benefits of arthroscopic instability repair over open procedures
less surgical morbidity, equal healing rates and outcomes
following instability repair, what plane should the pt be working in?
scapular plane to dec stress on anterior capsule, increases bony congruency. later, move into coronal plane.
following instability repair, which planes are usually ok for physio ROM?
flexion, scaption, horiz add, IR
following plication what motions may be restricted
ER or IR
what is plication?
removing capsular redundancy by creating a fold in capsular tissue
gold standard tx for anterior instability
open bankart - restores tension to the anteroinferior capsule and inferior GH ligament complex, fixes labrum
surgical interventions of SLAP lesions I II III IV
I debridement (or conservative)
II repair biceps anchor attachment
III debridement of bucket handle type tear
IV same as III, biceps anchor repair, biceps tenodesis or tenotomy
which ligaments are injured with AC joint separation
acromioclavicular and CC ligaments (conoid and trapezoid)
AC joint ligaments provide stability in which plane?
CC ligaments provide stability in which plane?
AP
vertical stability
AC jt separation types
I
II
III
I sprain without tear
II rupture of AC capsule and ligs without injury to CC
III complete rupture of AC and CC ligs = step off due to acromion depression.
imaging for AC jt
AP, IR and ER, scapular Y, axillary
stryker notch view may be taken in a complete AC dislocation if the normal CC interval is maintained. indicating a possible fractured coracoid process.
which AC jt separation types usually require nonoperative tx
I and II
trial with III for at least 3 mo
nonoperative tx for AC jt injury
I and II
1) NSAIDs, PT, possible injection, immobilization, AAROM in low positions
2) when 75% ROM –> full ROM, strengthening without bench press/military press
3) strengthening into provocative positions
4) sport specific
when is sx considered for type III AC jt injury initially?
- thin pts with significant visual deformity.
- sustained or repetitive sh level positioning
- lift heavy weights
what to do with type III AC jt injury?
lack of evidence to support sx
immobilization time and return to work/sport is quicker with conservative tx
greater pain satisfaction with sx
association between chronic type III AC jt injury and CS?
increased cervical hypolordosis and increased C/S symptoms with ACJ injury
AC jt conservative tx should emphasize which muscle
upper trapezius activation and endurance
how long is the protective phase for AC jt sx?
4-6 wks with a sling
pt can do pendulums, AAROM in all planes
3 phases of AC jt sx rehab
1) 0-4wk protective using a sling and firm pillow
2) 4-12 wks gradual return of motion, avoid strengthening >90 deg elevation
3) 12-24 wks return to sport
frozen shoulder affects what % of gen pop?
ppl with DM and thyroid disease
- 35-5%
10. 8-38
typical age of frozen shoulder
40-65yo
females > males
etiology of frozen shoulder
elevated serum cytokine levels (growth factors) causing fibrosis in the capsuloligamentous complex (CLC)
Rotator cuff interval - what is it?
forms the triangular shaped tissue between anterior supraspinatus tendon and upper subscap border.
including superior GH lig and coracohumeral lig.
anterior superior hammock restricting ER and preventing inferior translation
primary frozen shoulder
not associated with a particular systemic condition or hx of injury
secondary frozen shoulder
systemic
extrinsic
intrinsic
systemic - DM, thyroid disease
extrinsic - MI, cervical disc disease
intrinsic - RC/biceps tendinopathy
typical ROM findings in frozen sh
elevation
ER
capsular pattern
<120 with scapular substitution
50% or <30
limitations in ER > abd > IR
typical strength deficits in people with frozen sh
IR, elevation
modalities that may be effective with frozen sh
moist heat
short wave diathermy with stretching
TENS with low load stretch
no US!
when should corticosteriod injections be used for frozen sh?
first 3-6 wks of intervention
benefit of corticosteriod use for frozen sh
no differences long term
hastening the time to achieve end range fibrotic tissue by decreasing discomfort at rest
what percent of pts undergo MUA for frozen sh?
7-10%
secondary OA definition
posttraumatic and postsurgical (intraarticular fx or capsulorraphy)
inflammatory arthritis includes
RA, ankylosing spondylitis, psoriatic arthritis
potential causes for AVN or autraumatic osteonecrosis
corticosteroid use, alcoholism, gaucher disease, sickle cell, irradiation
how do you gain access to GHJ with shoulder arthroplasty?
deltopectoral incision,
subscap release at tendon or osteotomy of lesser tuberosity
upper pec major can be released if IR contracture
osteotomy of the humerus is made where for sh arthroplasty?
anatomic neck - 30 deg retroversion
sh arthroplasty - soft tissue balancing
sh is reduced, posterior translation should sublux the humerus 50% of its diameter
minimum of 30-40 deg ER
how much ER should the subscap allow during shoulder arthroplasty?
30-40 deg
what can be done if the posterior capsule is too lax during shoulder arthroplasty? consequences?
larger humeral head can be used
may compromise subscap length, then they do a capsular shift
prognosis for ppl with RA following TSA
poor due to less robust RC tissue compaired to primary OA - 24-30% have full thickness RC tear
are the lift off and abdominal compression tests reliable for subscap rupture assessment following arthroplasty?
no
what is the RC integrity of ppl with primary OA of the shoulder?
pretty good, therefore, good dynamic stabilization after TSA
- only 9% had RC tears - all in supraspinatus and repairable
which provides better outcomes? TSA or HA?
TSA
benefit of biceps tenodesis with shoulder arthroplasty
pain relief
effect of RA on sh elevation following TSA
average ROM TSA 2/2 RA
less active elevation
~100, 47 ER, IR L4
HA following acute fracture precautions
avoid too much passive ER - 50 deg
can people perform above shoulder activities following HA due to acute fx?
50% can
incidence of nerve lesions following acute sh fx - which nerves
axillary is most often affected
when can AROM be started after HA following TSA due to chronic fx arthritis
if greater tuberosity has been spared - 6 wks
if greater tuberosity osteotomized - 12 weeks
which outcomes are better:
arthroplasty due to osteonecrosis following steroid use or trauma?
steroid use
your pt has hx of posterior instability prior to TSA - what should you consider with elevation stretching?
scapular plane versus saggital plane to decrease tension on posterior capsule
if subscap was altered with a Z plasty or augmented with a graft, when may strengthening start?
12 weeks
criteria for standard goals group for TSA
competent RC and deltoid
adequate bone quality
stable joint
criteria for limited goals group for TSA
instability
RC/deltoid deficiency
tuberosity malposition
denervation
expected elevation and ER of limited goals
elevation <90 deg
ER 20
standard goals examples
OA RA with intact RC osteonecrosis acute proximal head fx posttraumatic without greater tuberosity osteotomy capsulorraphy arthroplasty
limited goals examples
RC arthropathy
RA with RC tear - irreparable
acute prox humeral head fx with migration
greater tuberosity osteotomy
septic arthritis
capsulorraphy arthroplasty with instability
