Shoulder Flashcards
What joint is on top of the shoulder?
AC (acromioclavicular) joint
What joint is what we think of as the shoulder?
GH (glenohumeral) joint
What is scapulothoracic?
scapula and ribs
What is sternoclavicular?
clavicle and sternum joint
What are the 4 rotator cuff muscles?
- supraspinatus
- infraspinatus
- teres minor muscle
- subscapularis muscle
What do we look for in shoulder assessment observations?
- forward head
- rounded shoulders
- winging scapula
How does forward head affect the shoulder?
pressure on nerves in neck, will refer to arm
How does rounded shoulders affect the shoulder?
shortened muscles on front, elongated muscles in back, changing how the arm sits
What is winging scapula?
scapula sits out from body, not tight to ribcage
Separations are specific to which joint?
AC joint
Dislocations are specific to which joint?
GH joint
Where does AC joint sprains occur?
at very top of shoulder
What is the MOI of AC joint sprains?
- vulnerable in collision sports
- FOOSH (upwards force on clavicle)
- ex. bike riders hitting ground, hockey players hitting boards
What are the signs and symptoms of a grade 1 AC joint sprain?
- stretch of ligaments, no tearing
- mild symptoms
What are the signs and symptoms of a grade 2 AC joint sprain?
- some stretch, some tearing
- moderate symptoms
- will see laxity with special tests
- will see some deformity
What are the signs and symptoms of a grade 3 AC joint sprain?
- rupture of all of the main ligaments in that joint
- not physically attached
- severe symptoms
- severe deformity
Grades 4-6 of AC joint sprains involve what?
fractures or displacement of the clavicle
What is step deformity?
- as you have less ligaments holding it, the end of the clavicle sneaks up
- tends to be lifelong
How do we manage 1st and 2nd degree AC joint sprains?
- RICE
- Modalities to calm down spasm
- Strengthen joint
- Regain ROM
How do we manage grades 3+ AC joint sprains?
- Need to be seen at the hospital
- Check for fractures
- Check to see if clavicle is still where it should be
- May need surgery (fracture: bar and pin)
- Immobilized in sling for usually 5-6 weeks
- Start doing some rehab at weeks 2-3
What are the special tests for AC joint sprains?
- physically looking for deformity
- cupping and pushing clavicle up and down
What are positive tests for AC joint sprains?
- Pain is 1st degree
- Pain and laxity is 2nd degree
- No pain and laxity is 3rd degree
- Grades 4-6 would not be able to touch it
50% of all dislocations occur where?
at the shoulder
dislocations =
- sprains and strains
In what direction do GH dislocations occur?
- can occur in any direction
- anterior dislocations are most common
- can go straight backward (arm gets hit, humerus goes backwards)
- can go inferior (arm abducted, hit on top)
Dislocations can either…
stay out or move out and come back into place
What is the MOI for GH dislocations?
- abduction with external rotation
- any large trauma to shoulder
What are subluxations?
- partly out of place and coming back in
- usually muscle or ligament stops it from going all the way out
Why do GH dislocations need to be seen by a doctor at a hospital?
- Arteries, veins, nerves, don’t want secondary injury
- X-rays
- Everything is sitting where it should
What is a complication from GH dislocations?
- Labrum is cup that sits inside shoulder blade
- Common to tear and have extra injury
- Makes rehab more complicated
What are the signs and symptoms of GH dislocations?
- sulcus deformity
- Pain and disability
- Can be physically stuck in the position
- Generally aching pain, not sharp pain
- Will have full movement in through elbow and hand
- No ability to move shoulder
- Can fully shoulder shrug (doesn’t involve GH joint)
What is sulcus deformity?
- Deltoid is holding humerus into place (being hung)
- Deltoid muscle will be very flat
- Will look like they have very little shoulder development on one side
What is backwards rehab?
scar the joint down
Doing too much early in rehab of GH dislocations could result in?
can turn into someone who can pop out shoulder all the time
Describe rehab for GH dislocations.
- backwards rehab
- Nothing to hold it back in place (ligaments and muscles are sprained and strained)
- Put in brace (big harness), left for 6 weeks, no ROM at shoulder
- Can start isometrics in that position
- After 6 weeks, if it seems fused in there, then we will start ROM
- All ROM is to be below 90 degrees (horizontal)
- After 3 months post injury, we add ROM above 90 degrees
What are the special tests for GH dislocations?
- sulcus test
- apprehension position
- anterior and posterior drawer
What is the sulcus test?
- Flattened deltoid
- Pull down on arm to create more of an effect
- Will see gap below acromion
What is apprehension position?
- Full external rotation with abduction
- Will not like their position
- Uncomfortable and unstable
- Makes it feel like their shoulder is going to pop out
Describe the anterior drawer and what a positive test looks like.
- physically pulling humerus forward, stressing ligaments on anterior side of joint
- Laxity: more movement forward
- Need to make sure pecs are stronger
Describe the posterior drawer and what a positive test looks like.
- Physically pushing humerus backward, stressing ligaments on posterior side of joint
- Laxity: more movement backward
- Need to make sure rotator cuff muscles and triceps are stronger
What is the most commonly fractured bone in the body, especially in sport?
clavicle
What is the MOI for a clavicle fracture?
- FOOSH
- direct impact to the side of the body
- direct impact to the clavicle itself
Which part is the weakest part of the clavicle?
part in bone that changes direction
What are the signs and symptoms of a clavicle fracture?
- Inflamed at site
- Can be obvious deformity
- Even if it is just a crack, there will be a deformity (bump)
- Point tender
- Lot of heat
- Lots of redness
What is a complication from clavicle fractures?
- Blood vessel going to arm is right underneath
- No feeling in fingers or pulse in arm = medical emergency
- Lots of bruising from direct hit = ambulance (could have hit subclavian artery)
What do we do for people with clavicle fractures immediately?
want to support their arm and tilt their head that way
What do they do with clavicle fractures if the 2 pieces are not connected?
pin
pins and plates =
less immobilization
no pins and plates =
longer immobilization
Describe the management for clavicle fractures.
- 6-8 weeks immobilization
- can follow normal protocol for rehab after immobilization (not like dislocations)
What is the special test for clavicle fractures?
- no special test
- will hate horizontal (cross) flexion (adduction)
Describe the anatomy of why biceps tendonitis occurs.
- Long head tendon sits in grove on front of shoulder, white membrane overtop
- Structural issue (grove not formed properly)
Biceps tendonitis usually occurs in …..
the long head (in front of shoulder)
What is the MOI for biceps tendonitis?
- Overhead activities irritate (back strokers, volleyball players)
- Overuse
What are the signs and symptoms of biceps tendonitis?
- Pain locally at front of shoulder
- Long head biceps tendon is point tender
- Mild inflammation right at the front of the shoulder
- Won’t change based on degree
- Crepitis in tendon
- Tendonitis: hurts after the sport… usually won’t stop playing
- Usually won’t come see you until stage 3 where it affects their sport
People with biceps tendonitis will have pain with … but no pain with ….
- pain with anything over head (only in the front of the shoulder)
- no pain with anything involved with biceps at the elbow (elbow flexion)
How do we manage bicep tendonitis?
- Not likely for them to stop doing whatever it is that is causing the problem
- Ultrasound to break down scar tissues
- Local
- Current to calm down swelling and pain
- Laser to help it heal
- Something to help them during activity
What is the stretch for long head of biceps?
arm behind, raised, roll shoulder forward, burning
feeling
What is the special test for biceps tendonitis?
speeds test
Describe the speeds test.
- Firing the long head biceps
- Arm straight, flexed at 60 degrees in front
- Resisting shoulder flexion (not elbow flexion)
- Will have pain local to where the biceps tendon is
- Only pain, not laxity
- Long head biceps is tender
What is happening anatomically for someone with shoulder impingement?
- Supraspinatus tendon and bursa and long head of biceps tendon come in between acromion and head of humerus
- No space for anything to be inflamed, one of the tissues are damaged and inflamed, making less space for everything else in the channel
How can bone cause shoulder impingement?
- Rounded shoulders can bring 2 bony surfaces together
- Less room for structures in channel
We typically see shoulder impingement in people that do lots of _______ activities. Give examples.
- overhead
- ex. Swimmers, volleyball players, painters, roofers, siders etc.
What is the tell tale sign for shoulder impingement?
painful arc
Describe the painful arc.
- When they abduct their arm, from 60 degrees to 120 degrees, they have pain
- No pain from 0-60 degrees
- No pain at very top of movement
- Aching type sensation, not burn
- Generally will point to glenohumeral joint
What is responsible for the first 30 degrees of shoulder abduction?
supraspinatus
How do rotator cuff tendons affect shoulder impingement?
- Rotator cuff tendons attach onto humerus
- Pull humerus into right position so that channel is big enough
- If they are not doing that, there is not enough space
What are the signs and symptoms of shoulder impingement?
- Can see swelling, heat, redness: depends on how bad it is, generally not because deltoid is overtop
- Aggravated from doing more things overhead
Overuse injury means …
we probably won’t see them until stage 3
How does stretching the supraspinatus help relieve symptoms of shoulder impingement?
tight muscle = shortened = taking up more space in channel
How do we manage shoulder impingement?
- stretch supraspinatus
- rotator cuff exercises
- scapular stabilization exercises
- do all modalities locally
- ultrasound won’t do much
- need to solve problem, not numb it
Give examples of rotator cuff exercises.
External rotation: weight on side, tubing, cable
Give examples of scapular stabilization exercises.
- Pull scapula back and down, hold, release
- Lying on stomach, hold position
- Retract scapula and do Ts, Ys, and Is
- 3 sets of 10
- Slow steady movement and do not release retraction or position until the rep is done
- Rotator cuff movement in overhead type movement
What is the special test for shoulder impingement?
neers test
Describe the neers test.
- Passive abduction above their head
- Pain in middle of movement 60-120 degrees
- Pain in ROM, no laxity
- Might physically be stuck if it is really bad
What is the other name for frozen shoulder?
Adhesive Capsulitis
What is happening anatomically for someone with frozen shoulder?
- Capsule of shoulder blade is completely stuck down
- Allows no movement
- Completely restricts ROM in shoulder
- Generally happens in people over the age of 45, but can happen at any age
- humeral head pulled in
What is the MOI for frozen shoulder?
- No idea why this happens
- No MOI
What is the typical cycle that someone with frozen shoulder will go through?
- 6-6-6
- Worse for 6 months
- Stays the same for 6 months
- Gets better for 6 months
- Regardless of what we do
- No pain, physically cannot get their arm past 60 degrees (passive, active)
How much shoulder movement does someone with frozen shoulder have?
About 60 degrees of movement in shoulder in every direction
What needs to happen anatomically to move the shoulder past 60 degrees?
- Related to rhythm of movement in shoulder complex
- First 60 degrees is only glenohumeral joint
- Past 60 degrees, shoulder blade (scapula) needs to move as well
- Scapulothoracic rhythm
- 2 to 1 ratio, shoulder blade moves twice as much
- Once at 120 degrees, clavicle needs to move up, rotate back
How do we manage frozen shoulder?
- Calm down any other muscle spasms going on in shoulder and neck
- Local treatment
- Can do all modalities but won’t make ROM of shoulder any better
- Just to make them as comfortable as possible
What is the special test for frozen shoulder?
- no special test
- Can’t get past 60 degrees actively or passively
Where do humeral fractures occur?
- Can fracture anywhere along humerus
- Most common in shaft or neck
- Generally in top half of humerus
What is the MOI for humeral fractures?
- MOI: direct impact
- MOI: FOOSH
- Can get this from complication from dislocation of shoulder or elbow
Why are small humeral fractures hard to see?
- Large muscle mass in biceps and triceps can make small fractures hard to see
- Difficult to palpate humerus
- Palpate humerus in between muscle mass on front and back
What are the signs and symptoms of humeral fractures?
- Through and through break = translation (not lined up)
- Muscles are strong, will pull bones out of place if they are apart
- Cause nausea, feel physically ill
What are complications that can arise from humeral fractures?
- Top half of humerus: watch for brachial artery
- Nerves run close to bone in upper half of humerus
- Any pins and needles, tingling or can’t find pulse = ambulance
- Big red bruise where brachial artery is = ambulance
How do we manage humeral fractures?
- Stabilize
- X rays
- Smaller breaks = cast (4-6 weeks) usually in 90 degree arm bend
- Because of muscle mass that can pull
- Through and through break = pinned or plated
- Bones solidify in first 2-3 weeks
Give rehab and exercises in cast after 2-3 weeks for humeral fractures.
- Isometric exercises
- Flexion and extension of elbow
- Flexion and extension of wrist
- Ball squeezes (muscles in forearm)
- No ROM at elbow
What is the special test for humeral fractures?
- Palpation
- Either side (medial and lateral) of muscle mass
- Ridiculous amount of point tenderness
Biceps generally rupture or strain at the ______ of the muscle.
top
Triceps generally rupture or strain at the ______ of the muscle
bottom or top third
What are the signs and symptoms of a grade 1 muscle strain?
- Mild symptoms
- Stretching no tearing
- Full function
- Pain
What are the signs and symptoms of a grade 2 muscle strain?
- Tearing
- Loss of function
- Loss of strength (resisted testing)
- bruising
What are the signs and symptoms of ruptured biceps or triceps?
- Rupture
- Biceps rupture at top, sit in a ball at elbow
- Rupturing biceps: brachialis underneath, will still be able to flex
- Hear pop or snap
- Triceps rupture at either end
Rupture at bottom =
hang
Rupture at top =
roll up in a ball
How do we manage Muscle Strains and Ruptures to Biceps and Triceps?
- Decrease inflammation, pain
- Increase strength
- Ruptures will be surgically repaired
What is the special test for muscle strains and ruptures to the biceps and triceps?
for muscle strength: resisted ROM
Describe the resisted ROM test.
- Grade 1: pain
- Grade 2: pain and lack of strength
- Grade 3: complete loss of strength
