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OCS > Shoulder > Flashcards

Shoulder Flashcards

1
Q

GHJ joint type

A

Synovial joint rotating around 3 axes

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2
Q

Humeral head positioning

A

-facing medially, posteriorly, superiously

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3
Q

Angle of inclination

A

-the head is inclined approximately 130* from long axis of shaft

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4
Q

Retroversion

A

-rotation of the humeral head in the transverse plane is 30*

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5
Q

Glenoid fossa position

A

7* laterally from scapula and oriented posteriorly with a slight 5* superior tilt relative to medial border of scapula

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6
Q

Labrum

A
  • deepens the foss and supplies a negative intraarticular vacuum effect -sealing the joint
  • assists with stability
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7
Q

GHJ capsule

A

along with ligaments have double the surface area of the humeral head itself
-capsule arises form glenoid neck and labrum - inserts on articular margin of anatomical neck of humeral head (except inferomedially where it extends down the humeral neck)

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8
Q

2 openings in GHJ capsule

A

1) between humeral tubercles allowing biceps tendon to exit the joint
2) connection between joint and subscapularis bursa

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9
Q

Inferior GHJ capsule

A

-very redundant to allow for greater ROM

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10
Q

Anterior & Posterior capsule

A
  • posterior is thin

- extracapsular ligaments surround superior and anterior joint

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11
Q

Superior GH ligament

A

-either a robust or thin tissue that provides restraint to inferior translations of humeral head when arm is adducted

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12
Q

Middle GH ligament

A

-restraint to anterior humeral translation with the arm in mid-range of abduction up to about 45* and also limits ER with arm at side

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13
Q

Inferior GH ligament complex

A
  • expansive band of tissue in the inferior capsule - thickened anterior and posterior band
  • “hammock” type axillary pouch
  • anterior band works in conjunction with anterior and posterior bands to limit anterior translation in either direction when the GHJ is abducted to 90*
  • in ER and abduction - anterior band wraps around front of GHJ to limit anterior translation
  • in IR - posterior band prevents posterior translation
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14
Q

Scapulothoracic joint

A
  • not a true joint

- between anterior scapula and posterior thorax and rib cage

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15
Q

Scapula superior and inferior border and scapular angles

A
  • 2nd thoracic vertebrae
  • 7th thoracic vertebrae
  • angled 30-40* from coronal plane to place glenoid fossa anteriorly - “scapular plane”
  • upwardly rotated 10-20* from vertical and tips 10-20* anteriorly
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16
Q

Sternoclavicular joint

A
  • saddle shaped joint (diarthrodial)
  • inherently unstable, but one of the least dislocated joints
  • allows motions of protraction/retraction, elevation/depression, and rotation
  • only true skeletal articulation between the axial region and UE
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17
Q

SC joint disc

A
  • helps with stability and separates joint into 2 compartments
  • medial end of clavicle is concave in the AP direction and convex in the SI direction
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18
Q

SC joint capsule

A
  • surrounds entire joint

- weak and supported by thickenings called AP SC ligaments

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19
Q

Posterior SC ligament

A

-causes significant increases in AP translations - greater than that of any ligament

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20
Q

Interclavicular ligament

A
  • medial ends of both clavicles

- thought to provide restrains to inferior forces on medial end of clavicle

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21
Q

Costoclavicular ligament

A

-anterior and posterior bundles that run from superior surface of the first rib to the undersurface of clavicle

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22
Q

AC joint

A
  • synovial planar joint with 3* of freedom
  • articular disc lies between 2 surfaces - provides stability improving fit between 2 surfaces
  • hyaline cartilage becomes fibrocartilage by age 17 on acromial side and by age 24 on clavicular side
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23
Q

AC joint capsule

A

-surrounds to help provide stability

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24
Q

Conoid and trapexoid ligaments (coracoclavicular ligaments)

A

-provide stability medial to the AC joint

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25
Q

Conoid ligament

A
  • runs vertically between coracoid process and clavicle

- resists clavicle elevation and protraction

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26
Q

Trapezoid ligament

A
  • runs in a superolateral direction between coracoid process and clavicle
  • limits same motions as conoid as a secondary role eto AC joint compression
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27
Q

Scapulohumeral rhythm

A
  • contributions made by multiple joints for shoulder elevation
  • original was “2 to 1” = 2* of GH motion for every 1* of scapular motion
  • others have said 1.25:1 or 4:1
  • 1208 humeral elevation and 60* scapular rotation
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28
Q

Deltoid-RC force couple

A
  • largest amount of force
  • during initial arm elevation - more powerful deltoid has directional force on humerus that is upward and outward
  • if this motion is unopposed - resultant superior migration would impact greater tub into acromion
  • counteracted by inferior and medial directed force of infraspinatus, subscap, teres minor
  • supraspinatus provides direct compression force
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29
Q

RC muscles

A
  • supraspinatus
  • infraspinatus
  • teres minor
  • subscapularis
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30
Q

RC not functioning properly, then

A

pressure from humeral head onto coracoacromial arch is increased by 60%

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31
Q

UT-serratus anterior force couple (4 crucial functions)

A

1) allows for rotation of scapula, maintaining the glenoid surface for optimal positioning
2) maintains efficient length tension relationship for deltoid
3) prevents impingement of the RC from the subacromial structures
4) provides stable scapular base enabling appropriate recruitment of scapulohumeral muscles

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32
Q

UT-serratus anterior force couple synergistics

A

Lower portion of serratus anterior and lowe rtrap contract in conjunction with UT and levator scap to create upward scapular rotation throughout elevation
-serratus and lowe rtrap are primary components of upward rotation and scapular stab in the abducted shoulder near 90* and more of elevation

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33
Q

Impingement and UT-serratus anterior force couple

A
  • decreased levels of serratus anterior activity
  • delay in firing of middle and lowe rtrap
  • dominance in UT and levator scap activity
  • faulty scapulohumeral rhythm
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34
Q

Anterior-posterior RC force couples

A
  • anterior based subscap and posterior based infraspinatus and teres minor work together = inferior dynamic stability and concavity compression mechanism
  • known to be active in the mid ranges of shoulder elevation
  • depress humeral head and comperess into glenoid
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35
Q

Imbalances in anterior-posterior force couples

A

-frequently found due to selective development of IR and subscap in athlestes without concominant development of posterior cuff

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36
Q

Shoulder posture

A
  • dominant shoulder is sig. lower in neutral, non-stressed standing postures
  • hands on hips position allows patient to relax and enables clinicians to observe focal pockets of atrophy
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37
Q

Testing of scapular dyskinesia

A
  • performed using kibler scapular slide test in neutral and 90* elevation
  • tape measure used to measure from thoracic spine to inferior angle
  • difference of 1cm to 1.5cm is abnormal
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38
Q

Kibler scapular exam techniques

A

-visual inspection from posterior view in resting, hands on hips, and during active movement bilaterally in sagittal, scapular, and frontal planes

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39
Q

Inferior angle scapular dysfunction

A
  • inferior border of scapula is very prominent
  • results from anterior tipping of scapula
  • most commonly seen in patient’s with RC impingement
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40
Q

Medial scapular border dysfunction

A
  • patient’s entire medial border being posteriorly displaced from thoracic wall
  • occurs from IR of the scapula
  • most often in patients with GHJ instability
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41
Q

Antetilting

A
  • IR of scapula leading to altered position of glenoid
  • allows for an opening up of anterior half of GH articulation
  • a component of subluxation and dislocation
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42
Q

Superior scapular dysfunction

A
  • early and excessive superior scapular elevation during arm elevation
  • typically results from rotator cuff weakness and force couple imbalances
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43
Q

Scapular assistance test (SAT)

A
  • assistance of scapula through examiners hands applied to inferior medial aspect of scapula - second hand at superior base - provide an upward rotation assistance motion while patient actively elevates
  • negation of symptoms or increased ease of elevation is a positive test
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44
Q

Scapular retraction test (SRT)

A

-retraction of scapula manually by examiner while a movement that was previously unable to be performed secondary to weakness or pain.

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45
Q

Flip sign

A
  • resisted ER at the side by the examiner with monitoring of medial scapular border
  • if medial border “flips” away from thorax and becomes more prominent = positive
  • indicates loss of scapular stability
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46
Q

Selective loss of GH IR

A
  • dominant extremity

- consistently reported in patient populations of overhead athletes

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47
Q

IR ROM loss leads to

A

tightness in posterior capsule an dincreased anterior humeral head translation
-as well as superior migration of humeral head during shoulder elevation

48
Q

MMT position for supraspinatus

A
  • 90* elevation with patient seated
  • scapular plane
  • ER of the humerus so forearm is neutral
  • “full can” position
  • “empty can” can also be used
49
Q

MMT position for infraspinatus

A
  • seated position
  • 0* GH joint elevation
  • 45* IR
50
Q

MMT position for teres minor

A
  • patte test best ioslates

- 90* GHJ abduction in scapular plane and 90* ER

51
Q

MMT for subscap

A

-gerber lift off position (hand behind back)

52
Q

Impingement tests

A
  • Neer impingement sign
  • Hawkins-kennedy
  • coracoid impingement test
  • cross arm adduction
  • yocum test
53
Q

Neer test

A
  • forced flexion
  • sp - 53%
  • sn - 79%
54
Q

Hawkin’s kennedy

A

sp - 59%

sn - 79%

55
Q

Yocum test

A

-active combination of elevation with IR (cross hand over to opposite shoulder and lift elbow towards nose)

56
Q

Instability tests - 2 main types

A
  • humeral head translation

- provocation

57
Q

Instability humeral head translation tests

A
  • sulcus sign

- translation in inferior direction

58
Q

Graded translation

A

I- humeral translation within glenoid without edge loading or translation over glenoid rim
II - translation of humeral head over glenoid rim with spontaneous return on removal of stress
III - not seen clinically, involves translation of humeral head without relocation upon removal of stress

59
Q

Primary labral tears

A
  • most off in anterior-superior (60%) or posterior superior (18%)
  • only 15 tear in atnerior inferior
60
Q

Bankart lesion

A
  • found in 85% of dislocation
  • labral detachment that occurs between 2 oclock and 6 oclock on the (R) shoudler and between 6 oclock and 10 oclock on (L) shoulder
  • anterior inferior detachment decreases GHJ stability
  • increases anterior-inferior humeral head translation
61
Q

SLAP

A
  • supieror labrum anterior to posterior lesion

- commonly involves biceps long head tendon injury

62
Q

“Peel back” mechanism

A
  • SLAP lesion

- torsional force created when abducted arm is brought into maximal ER - peel’s back the biceps and posterior labrum

63
Q

Tests for labral pathology

A
  • long axis compression exerted through the humerus to scour the glenoid and attempt to trap torn or detached fragment between the head and glenoid
  • circumduction clunk test
64
Q

Circumduction and clunk test

A

-literally scour teh perimeter of the glenoid

65
Q

Other labrum tests

A
  • specifically use muscular tension exerted in the bicep lng head to tension superior labrum (obrien active compression test, mimori test, bicep load test, and ER supination tests)
  • specifically mimic the peel back mechanism
66
Q

Best imaging for labrum tear

A

-contrast MRI or MRI arthorgram

sn from 67-92%

67
Q

Radiograph standard imaging views

A
  • AP (ER/IR)
  • Scapular Y view
  • axillary views
68
Q

AP radiograph

A
  • medial humeral head slightly overlaps posterior glenoid
  • more than 7-8mm of distance between bottom of acromion and top of humeral head = sublux or dislocation
  • greater tuberosity seen clearly when arm is laid in er with forearm supinated
69
Q

Hill - sachs lesion

A

-occurs as posterior head is impacted on anterior glenoid when dislocated

70
Q

Reverse hill-sachs

A

-during a posterior dislocation when anterior head impacts posterior glenoid

71
Q

CT scans

A
  • needed for subtle or complex fractures

- used to view hill-sachs or reverse hill sachs

72
Q

MRI

A
  • used for musculoskeletal pathology
  • ligaments, capsules, synovium, labrum, extraarticular structures
  • adding contrast increases ability to determine RC tears and labral tears
73
Q

CKC UE stability tests

A
  • perform a power test of shoulder complex
  • 2 pieces of athletic tape 3 feet apart on floor
  • patient assumes standard pushup position with hands just inside the 2 pieces of tape
  • patient is instructed to move hands as rapidly as possible from one tape line to the other - touching each line alternatively in windshield wiper type fashion
  • number of touches performed in 15 seconds counted
74
Q

Functional throwing performance index

A

-series of repetitive throws at a target where both accuracy and ability to functionally perform the thorwing motion are scored

75
Q

Primary impingement (primary compressive disease)

A
  • impingement as a direct result of compression of RC tendons between humeral head and overlying anterior third of acromion, coracoacromial ligaemtn, coracoid, and acromioclavicular joint
  • peak forces between 85* to 136* of elevation
76
Q

Stage I primary impingement

A
  • edema and hemorrhage
  • results from mechanical irriation of tendon by impingement with overhead activity
  • younger patients who are athletic
  • reversible with conservative PT
  • s/s are similar to other two stages of impingement
  • impingement sign, painful arc, varying muscle weakness
77
Q

Stage II primary impingement

A
  • fibrosis and tendonitis
  • repeated episodes of mechanical inflammation and may include thickening or fibrosis of subacromial bursae
  • 25 to 40 year olds
78
Q

Stage III primary impingement

A
  • bone spurs and tendon rupture
  • result of continued mechanical compression
  • full thickness RC tears, partial thickness tears, bieps tendon lesions, bony alteration so facromion and AC joint associated with this stage
79
Q

3 types of acromion structure

A

1) flat
2) curved
3) hooked

Type III related to full thickness RC tear

80
Q

Secondary impingement (secondary compressive disease)

A
  • impingement from underlying instability of GHJ
  • attenuation of static stabilizers of GHJ, such as capsular l igaments and labrum from excessive demands incurred with throwing or overhead activities.
  • progressive loss of GHJ stability is created and secondary impingement can lead to RC tears
81
Q

Tensile overload

A
  • another etiologic factor in RC tear
  • heavy, repetitive eccentric forces during deceleration and follow through phases of overhead sport activities can overload tendon
82
Q

Angiofibroblastic hyperplasia

A

-occurs in early stanges of tendon injury and can progress to RC tears

83
Q

Macrotraumatic tendon failure

A
  • previous or single traumatic even in clinical history
  • forces encountered are greater than tendon can tolerate
  • full thickness tears with bony avulsions can result from single traumatic episodes
84
Q

Posterior or “undersurface” impingement

A
  • shoulder in 90/90 position causes the supraspinatus and infraspinatus tendons to rotate posteriorly
  • posterior orientation aligns them such that the undersurface of tendon rubs on posterior superior glenoid lip and becomes pinched or compressed between the humeral head and posterior glenoid rim
  • posterior shoulder pain brought on by 90/90 - typically overhead postiions in sport or industrial situations
85
Q

Modalities and early management of tendon pathology

A

-research is lacking regarding ID of clear superior modality or sequence of modlaities

86
Q

Key components of early RC pathology management

A
  • scapular stabilization
  • submax RC exercise
  • ROM and mobilization
87
Q

Mobilization and secondary RC impingement or tensile overload

A

-should not undergo accessory mobilization techniques due to capsular laxity already present

88
Q

Recommended reps

A

3 sets of 15-20 reps to create fatigue response and improve local muscular endurance

89
Q

Full thickness RC sizes

A

small - less than 1 cm across the full thickness defect
medium - 1cm to 3 cm
large - 3cm to 5cm
massive tears - larger than 5cm

90
Q

30* and 60* of ER vs. neutral rotation

A

-30* and 60* of ER actually show decrease in tension within the supraspinatus

91
Q

30* and 60* IR

A

increase tension within supraspinatus tendon

92
Q

Cross arm adduction and tendon strain

A

-no increase in strain in either infraspinatus or suprasinatpus at 60* elevation

93
Q

Weight and pendulums

A

-not recommended due to potential unwanted anterior translation

94
Q

Muscle activation at baseline vs. with therapy activity

A

Supraspinatus remained as passive as baseline during therapist-assisted and self-assisted ER, therapist assissted elevation, pendulums, and isometric IR and adduction

95
Q

Early vs. delayed ROM following RCR

A
  • systematic review found insufficient evidence
96
Q

Key areas for rehab of instability

A
  • education
  • activity modification
  • improving RC and scapular muscle strength and endurance
97
Q

Review post op goals for

A

RC and stability

98
Q

Capsular shift and pliaction

A

-goal is to create a fold in capsular tissue to remove unwanted capsular redundancy

99
Q

Arthroscopic anterior capsulolabral repair

A
  • redundancy is taken up through capsular placation or use of biodegradable sutures
  • anchors are placed in glenoid rim to repair labral tear and sutures create tightening of capsule back to labrum
100
Q

Bankart reconstruction

A
  • open procedure is gold standard for anterior instability

- restores tension to anteriorinferior cpsule adn inferior GH ligament complex

101
Q

Anterior latarjet

A
  • used for years to treat chronic shoulder instability when repair of labrum isn’t possible
  • indications include anterior bone loss, large hill-sachs lesion, general instability related to loss of function
  • combines stabilizing effects from transfer of coracoid bone block anterior with tenodesis effect of attached tendons on coracoid during transfer
102
Q

Surgical intetrvention based on SLAP lesion

A

Type I - debridement
Type II - repair biceps anchor attachment
Type III - debridement of bucket-handle type tear
Type IV - same as III; repair biceps anchor or complete biceps tenodesis or tenotomy

103
Q

AC joint x-ray images

A
  • AP
  • IR
  • ER
  • scapular Y
  • axillary
104
Q

AC joint sprain types

A

I - sprain without tearing
II - AC ligament and capsule are ruptured without injury to CC ligaments. Clavicle subluxes with 50% of cases
III - complete rupture of AC and CC ligaments - resutls in “step off” deformity at lateral shoulder
IV-VI - involve rupture of AC and CC ligaments with increasing degrees of soft tissue trauma and clavicular displacement

105
Q

AC joint Type I-III rehab

A
  • typically managed conservatively
  • immobilization
  • rest
  • ice
  • ROM exercise
  • NSAIDs
106
Q

Motions that place additional stress on AC joint

A
  • IR behind the back
  • horizontal adduction
  • end range flexion and extension
107
Q

Time frame for AC joint to consider surgical intervention

A

3 months of conservative 1st

-may also be considered for severe injury or those who do repetitive lifting above shoulder level

108
Q

Adhesive capsulitis

A
  • panful and limited AROM and PROM
  • particularly ER at the side and in varying degrees of shoulder abduction
  • typically between 40 and 65 years old
  • females more than males
109
Q

Etiology of adhesive capsulitis

A

-unknown

110
Q

Phases of adhesive capsulitis

A

1) Painful phase - pre-adhesive, mild erythema, last up to 3 months, sharp pain at end ranges, achy pain at rest, sleep disturbance, often misdiagnosed with RC impingement
2) Stiff phase, acute “freezing” phase, thickened red synovisitis during 3-9 month period, acute discomfort and very painful end ranges of all motions
3) Frozen phase - demonstrate less synovitis, but more mature capsuloligamentous fibrosis
4) Thawing phase - severe capsular restriction without significant siynovitis. PAinless stiffness

111
Q

Primary adhesive capsulitis

A
  • idiopathic

- not associated with systemic condition or hx of injury

112
Q

Secondary adhesive capsulitis

A
  • systemic (diabetes, thyroid)
  • extrinsic (CVA, MI, COPD)
  • intrinsic (RC, biceps tendinopathy, calcific tendinitis, AC or GHJ arthropathy, fractures)
113
Q

Adhesive capsulitis high irritability factors

A

1) high pain (>7/10)
2) consistent night or resting pain
3) high disability on outcome tool
4) pain prior to end ROM
5) AROM < PROM secondary to pain

114
Q

Adhesive capsulitis moderate irritability factors

A

1) moderate pain (4-6/10)
2) intermittent night or resting pain
3) moderate disability on outcome tool
4) pain at end ROM
5) AROM = PROM

115
Q

Adhesive capsulitis low irritability factors

A

1) low pain (<3/10)
2) no resting or night pain
3) low disability on outcome tool
4) minimal pain at end ROM with OP
5) AROM = PROM

116
Q

Capsular pattern

A

ER > ABD > IR

117
Q

Adhesive capsulitis and corticosteroids

A
  • strong evidence supports intraarticular corticosteroid injection to provide improvement of symptoms in first 3-6 weeks of intervention
  • no long term differences

OCS (13 decks)

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