Shoulder Flashcards
GHJ joint type
Synovial joint rotating around 3 axes
Humeral head positioning
-facing medially, posteriorly, superiously
Angle of inclination
-the head is inclined approximately 130* from long axis of shaft
Retroversion
-rotation of the humeral head in the transverse plane is 30*
Glenoid fossa position
7* laterally from scapula and oriented posteriorly with a slight 5* superior tilt relative to medial border of scapula
Labrum
- deepens the foss and supplies a negative intraarticular vacuum effect -sealing the joint
- assists with stability
GHJ capsule
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)
2 openings in GHJ capsule
1) between humeral tubercles allowing biceps tendon to exit the joint
2) connection between joint and subscapularis bursa
Inferior GHJ capsule
-very redundant to allow for greater ROM
Anterior & Posterior capsule
- posterior is thin
- extracapsular ligaments surround superior and anterior joint
Superior GH ligament
-either a robust or thin tissue that provides restraint to inferior translations of humeral head when arm is adducted
Middle GH ligament
-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
Inferior GH ligament complex
- 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
Scapulothoracic joint
- not a true joint
- between anterior scapula and posterior thorax and rib cage
Scapula superior and inferior border and scapular angles
- 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
Sternoclavicular joint
- 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
SC joint disc
- 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
SC joint capsule
- surrounds entire joint
- weak and supported by thickenings called AP SC ligaments
Posterior SC ligament
-causes significant increases in AP translations - greater than that of any ligament
Interclavicular ligament
- medial ends of both clavicles
- thought to provide restrains to inferior forces on medial end of clavicle
Costoclavicular ligament
-anterior and posterior bundles that run from superior surface of the first rib to the undersurface of clavicle
AC joint
- 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
AC joint capsule
-surrounds to help provide stability
Conoid and trapexoid ligaments (coracoclavicular ligaments)
-provide stability medial to the AC joint
Conoid ligament
- runs vertically between coracoid process and clavicle
- resists clavicle elevation and protraction
Trapezoid ligament
- runs in a superolateral direction between coracoid process and clavicle
- limits same motions as conoid as a secondary role eto AC joint compression
Scapulohumeral rhythm
- 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
Deltoid-RC force couple
- 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
RC muscles
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
RC not functioning properly, then
pressure from humeral head onto coracoacromial arch is increased by 60%
UT-serratus anterior force couple (4 crucial functions)
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
UT-serratus anterior force couple synergistics
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
Impingement and UT-serratus anterior force couple
- decreased levels of serratus anterior activity
- delay in firing of middle and lowe rtrap
- dominance in UT and levator scap activity
- faulty scapulohumeral rhythm
Anterior-posterior RC force couples
- 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
Imbalances in anterior-posterior force couples
-frequently found due to selective development of IR and subscap in athlestes without concominant development of posterior cuff
Shoulder posture
- 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
Testing of scapular dyskinesia
- 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
Kibler scapular exam techniques
-visual inspection from posterior view in resting, hands on hips, and during active movement bilaterally in sagittal, scapular, and frontal planes
Inferior angle scapular dysfunction
- inferior border of scapula is very prominent
- results from anterior tipping of scapula
- most commonly seen in patient’s with RC impingement
Medial scapular border dysfunction
- patient’s entire medial border being posteriorly displaced from thoracic wall
- occurs from IR of the scapula
- most often in patients with GHJ instability
Antetilting
- 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
Superior scapular dysfunction
- early and excessive superior scapular elevation during arm elevation
- typically results from rotator cuff weakness and force couple imbalances
Scapular assistance test (SAT)
- 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
Scapular retraction test (SRT)
-retraction of scapula manually by examiner while a movement that was previously unable to be performed secondary to weakness or pain.
Flip sign
- 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
Selective loss of GH IR
- dominant extremity
- consistently reported in patient populations of overhead athletes
IR ROM loss leads to
tightness in posterior capsule an dincreased anterior humeral head translation
-as well as superior migration of humeral head during shoulder elevation
MMT position for supraspinatus
- 90* elevation with patient seated
- scapular plane
- ER of the humerus so forearm is neutral
- “full can” position
- “empty can” can also be used
MMT position for infraspinatus
- seated position
- 0* GH joint elevation
- 45* IR
MMT position for teres minor
- patte test best ioslates
- 90* GHJ abduction in scapular plane and 90* ER
MMT for subscap
-gerber lift off position (hand behind back)
Impingement tests
- Neer impingement sign
- Hawkins-kennedy
- coracoid impingement test
- cross arm adduction
- yocum test
Neer test
- forced flexion
- sp - 53%
- sn - 79%
Hawkin’s kennedy
sp - 59%
sn - 79%
Yocum test
-active combination of elevation with IR (cross hand over to opposite shoulder and lift elbow towards nose)
Instability tests - 2 main types
- humeral head translation
- provocation
Instability humeral head translation tests
- sulcus sign
- translation in inferior direction
Graded translation
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
Primary labral tears
- most off in anterior-superior (60%) or posterior superior (18%)
- only 15 tear in atnerior inferior
Bankart lesion
- 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
SLAP
- supieror labrum anterior to posterior lesion
- commonly involves biceps long head tendon injury
“Peel back” mechanism
- SLAP lesion
- torsional force created when abducted arm is brought into maximal ER - peel’s back the biceps and posterior labrum
Tests for labral pathology
- 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
Circumduction and clunk test
-literally scour teh perimeter of the glenoid
Other labrum tests
- 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
Best imaging for labrum tear
-contrast MRI or MRI arthorgram
sn from 67-92%
Radiograph standard imaging views
- AP (ER/IR)
- Scapular Y view
- axillary views
AP radiograph
- 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
Hill - sachs lesion
-occurs as posterior head is impacted on anterior glenoid when dislocated
Reverse hill-sachs
-during a posterior dislocation when anterior head impacts posterior glenoid
CT scans
- needed for subtle or complex fractures
- used to view hill-sachs or reverse hill sachs
MRI
- used for musculoskeletal pathology
- ligaments, capsules, synovium, labrum, extraarticular structures
- adding contrast increases ability to determine RC tears and labral tears
CKC UE stability tests
- 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
Functional throwing performance index
-series of repetitive throws at a target where both accuracy and ability to functionally perform the thorwing motion are scored
Primary impingement (primary compressive disease)
- 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
Stage I primary impingement
- 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
Stage II primary impingement
- fibrosis and tendonitis
- repeated episodes of mechanical inflammation and may include thickening or fibrosis of subacromial bursae
- 25 to 40 year olds
Stage III primary impingement
- 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
3 types of acromion structure
1) flat
2) curved
3) hooked
Type III related to full thickness RC tear
Secondary impingement (secondary compressive disease)
- 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
Tensile overload
- another etiologic factor in RC tear
- heavy, repetitive eccentric forces during deceleration and follow through phases of overhead sport activities can overload tendon
Angiofibroblastic hyperplasia
-occurs in early stanges of tendon injury and can progress to RC tears
Macrotraumatic tendon failure
- 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
Posterior or “undersurface” impingement
- 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
Modalities and early management of tendon pathology
-research is lacking regarding ID of clear superior modality or sequence of modlaities
Key components of early RC pathology management
- scapular stabilization
- submax RC exercise
- ROM and mobilization
Mobilization and secondary RC impingement or tensile overload
-should not undergo accessory mobilization techniques due to capsular laxity already present
Recommended reps
3 sets of 15-20 reps to create fatigue response and improve local muscular endurance
Full thickness RC sizes
small - less than 1 cm across the full thickness defect
medium - 1cm to 3 cm
large - 3cm to 5cm
massive tears - larger than 5cm
30* and 60* of ER vs. neutral rotation
-30* and 60* of ER actually show decrease in tension within the supraspinatus
30* and 60* IR
increase tension within supraspinatus tendon
Cross arm adduction and tendon strain
-no increase in strain in either infraspinatus or suprasinatpus at 60* elevation
Weight and pendulums
-not recommended due to potential unwanted anterior translation
Muscle activation at baseline vs. with therapy activity
Supraspinatus remained as passive as baseline during therapist-assisted and self-assisted ER, therapist assissted elevation, pendulums, and isometric IR and adduction
Early vs. delayed ROM following RCR
- systematic review found insufficient evidence
Key areas for rehab of instability
- education
- activity modification
- improving RC and scapular muscle strength and endurance
Review post op goals for
RC and stability
Capsular shift and pliaction
-goal is to create a fold in capsular tissue to remove unwanted capsular redundancy
Arthroscopic anterior capsulolabral repair
- 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
Bankart reconstruction
- open procedure is gold standard for anterior instability
- restores tension to anteriorinferior cpsule adn inferior GH ligament complex
Anterior latarjet
- 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
Surgical intetrvention based on SLAP lesion
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
AC joint x-ray images
- AP
- IR
- ER
- scapular Y
- axillary
AC joint sprain types
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
AC joint Type I-III rehab
- typically managed conservatively
- immobilization
- rest
- ice
- ROM exercise
- NSAIDs
Motions that place additional stress on AC joint
- IR behind the back
- horizontal adduction
- end range flexion and extension
Time frame for AC joint to consider surgical intervention
3 months of conservative 1st
-may also be considered for severe injury or those who do repetitive lifting above shoulder level
Adhesive capsulitis
- 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
Etiology of adhesive capsulitis
-unknown
Phases of adhesive capsulitis
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
Primary adhesive capsulitis
- idiopathic
- not associated with systemic condition or hx of injury
Secondary adhesive capsulitis
- systemic (diabetes, thyroid)
- extrinsic (CVA, MI, COPD)
- intrinsic (RC, biceps tendinopathy, calcific tendinitis, AC or GHJ arthropathy, fractures)
Adhesive capsulitis high irritability factors
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
Adhesive capsulitis moderate irritability factors
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
Adhesive capsulitis low irritability factors
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
Capsular pattern
ER > ABD > IR
Adhesive capsulitis and corticosteroids
- strong evidence supports intraarticular corticosteroid injection to provide improvement of symptoms in first 3-6 weeks of intervention
- no long term differences
