Shoulder Flashcards
Describe the purpose of the following force-couple relationships:
- Deltoid-rotator cuff
- Upper trapezius/serratus
- Anterior/posterior rotator cuff
- Deltoid translates humeral head anterior and is counteracted by inferior pull of infraspinatus, Subscapularis, and Teres minor and the compressive force of Supraspinatus
- Lower trapezius and serratus anterior important in stabilization of scapular at >90 deg of shoulder elevation/ ABD. There is too much influence of upper trapezius with up-rotation in patients with impingement
- When balanced, the rotator cuff stabilizes and compresses the humeral head but with selective training of IRs and not enough training of ERs, can cause imbalance
Kibler scapula slide test
> 1-1.5cm difference at 0 and 90 deg elevation = scapular dysfunction
Measure distance between thoracic SP and inferior angle of scapula
Kibler’s 3 Primary scapular dysfunctions and what they likely indicate
- Anterior tipping - lads to RC impingement
- Medial border winging - leads to GH instability
- Superior dysfunction - RC weakness and force couple imbalances
How do you MMT the rotator cuff muscles?
- Supraspinatus: full/empty can, champagne test
- Infraspinatus: neutral elevation and 45 deg IR
- Teres minor: 90/90 position
- Subscapularis: Lift off test
Supine anterior humeral head translation test
What positions test what ligaments?
What is the grading for this test?
0-30 ABD tests superior GH ligament
30-60 ABD tests middle GH ligament
90 ABD tests inferior GH ligament
Classification of Altcheck and Dines
I humeral translation in the rim
II translation over the rim its return when stress removed
III not seen in clinic -> no relocation on removal of stress
Beighton hyper mobility scale
What is considered + for hyper mobility?
- Passover hyperextension of 5th MCP
- Passive thumb opposition to forearm
- Elbow and knee hyperextension
- Standing trunk flexion with knees extended
Some say 2/9 others 4/9
Bankart vs SLAP lesion
Labral detachment injuries
Bankart: occurs in 85% of shoulder subluxations, anterior-inferior detachment; occurs between 2-6 o’clock on R and 6-10 o’clock on L
SLAP: superior detachment between 10-2 o’clock
Hill Sach’s lesion
Reverse hill sach’s lesion
When posterior humeral head hits the anterior glenoid fossa and causes divot in humeral head
During posterior dislocation when anterior head hits posterior glenoid
What do we want ER/IR ratio of shoulder strength to be?
66% in healthy individuals
Up to 75% when there is instability
What is primary impingement?
What are the stages?
What gets impinged?
Decrease in subacromial space causes direct compression of humeral head under acromion, CA ligaments, or ACJ
- Can cause abrasion of supra, infra, or biceps LH
3 stages:
1. Edema or hemorrhage
2. Fibrosis or tendonitis
3. Bony Spurs or tendon rupture
What is secondary impingement?
Underlying GH instability causes anterior instability of humeral head which leads to biceps/RC impingement and can lead to RCT
What is tensile overload of the shoulder?
Heavy repetitive eccentric forces of the RC tendon during deceleration of overhead sports leads to overload of tendon
Early phase causes angiofibroblastic hyperplasia
Can lead to RC tears
What is posterior/undersurface impingement
In 90/90 position, Supraspinatus and Infraspinatus rub against glenoid
What are the early goals for non-operative rehab of RC impingement?
Decrease pain to initiate sub max RC and scapular exercises
Normalize capsular relationship with mobs and stretching
Early submax RC and scapular activation
What are Jobe’s Isotonic RC Cuff Exercises?
SL ER
Prone extension
Prone horizontal abduction
Prone ER and 90/90
What are the sizes of small, medium and large RC tears?
What regions can be affected in partial-thickness RC tears?
What are types of full thickness RC tears?
Small <1cm
Medium 1-3cm
Large >3-5cm
Massive >5cm
Incomplete tears:
Superior surface (Bursal side) caused by compressive forces during impingement
Undersurface (articular side) caused by anterior translation/instability
Full thickness:
Crescent-shaped: not much retraction and directly repaired back to greater tuberosity
U-shaped
Operative management of RC tears - Protocol When does isotonic strength begin? When does UBE begin? When to begin submax isokinetic? When to begin return to sport?
Week 1-2 PROM, HEP PROM/AAROM, isometric submax strength
Week 3-6 AAROM, UBE, scapular strength, submax rhythmic stab
Wee 6-8 Isotonic resistance ex can be initiated
Week 8 closed chain and quadruped, UE plyos initiated
Week 10 isokinetic
Week 12 initiate return to sport
What are the criteria for progression to isokinetic exercise post- RCR?
When can this begin?
Week 10
Patient has IR/ER ROM greater than that used during the isokinetic ex AND
Patient can complete isotonic ex program pain free with 2-3# weight or medium resistance band
What criteria must be met to begin interval return programs post-RCR?
When can this be initiated?
IR/ER strength min of 85% Contralateral side
ER/IR ratio 60% or higher
Pain free ROM
Negative impingement and instability signs during clinical exam
Week 12
What are 4 types of surgical intervention for Labral repair?
Which one is gold standard for anterior stability?
What are the ROM stages for post-op rehab for each?
- Capsular shift and plication: for multidirectional instability
- week 3: 0-90; week 4-6 140; week 6-9 175 - Arthroscopic anterior capsulolabral repair (ACLR):
- week 3: 120-140; week 4-6 160 - Bankart reconstruction: gold standard
- week 0-3: 0-90; week 4-6 140; 6-8 150-165
- slower with ER ROM on going to 40-65 scapular plane until week 9 - Anterior latarjet: chronic shoulder instability where labrum cannot be repaired
Indications: anterior bone loss due to chronic dislocations, large Hill-Sach’s lesion, general instability related to loss of function
- caution with Subscapularis strengthening until week 6
What are the types of ACJ separations?
When is surgery indicated?
I sprain of AC without tear
II AC lig and capsule rupture but no CC ligament rupture subluxation 50%
III complete rupture of AC and CC ligaments
IV-VI rupture of AC and CC ligaments with increased soft tissue involvement
Surgery not indicated for Types I-III unless conservative management fails after 3 months
What are the stages of adhesive capsulitis?
- Pre-adhesive stage: mild synovitis that lasts up to 3 months and often mis-diagnosed as RC tear
- pain at end-range, at night, achy pain at rest - Freezing stage: 3-9 month period; a lot of pain at end-range of all motions
- Frozen stage: 9-15 month; less synovitis more fibrotic
- Thawing stage: 15-19 months; painless stiffness;
Indications of adhesive capsulitis
- ROM loss of 35% or greater in at least 2 planes
- passive ER loss >50% or ER less than 30
- Painless strength
- Capsular pattern: ER>ABD>IR
Precautions for shoulder arthoplasty:
Acute fx of humeral head - how to treat
Post-traumatic/fx arthritis - when to start AROM
Acute fx of humeral head: will be stiff but avoid aggressive stretching
Post-traumatic/fx arthritis:
- if greater tuberosity spared then AROM at 6 weeks
- If greater tuberosity osteotomy then AROM at 12 weeks
Post-op TSA
When can you begin strengthening?
What conditions will require limited goals?
What ROM can you expect with limited goals? When can this ROM be achieved
TSA: 0-3 PROM 90-120, isometrics at week 3, isotonic strengthening at week6
Limited goals: RC arthropathy, RA with irreparable RC tear, acute prox humeral head fracture with tuberosity concerns, post-traumatic arthritis with greater tub osteotomy, septic arthritis
Expect 90-120 AROM flexion at 12 weeks and 120-140 total; begin strengthening at 12-16 weeks
What is the protocol for Reverse TSA?
I 0-3 weeks PROM 90, ER 20-30
3- 6 weeks PROM 120-140
II 6-8 weeks AAROM/AROM, start strengthening deltoid so isometric to isotonic
What is TUBS? AMBRI?
Traumatic unilateral Bankart lesion
AMBRI: atraumatic multidirectional bilateral instability rehabilitation
