Shoulder Flashcards
What directions are the humeral head facing?
Medially, posteriorly and superiorly
What directions are the glenoid fossa facing?
Laterally from scapula, posteriorly with slight superior tilt
What area of the joint capsule is redundant to allow for greater ROM?
Inferior
What portion of the glenohumeral ligament limits ER with the arm at your side?
Superior
GH ligament
What ligament provides restraint to anterior humeral translation with the arm in mid-range?
Middle GH ligament
What portion of the joint capsule limits ER, superior & anterior translation?
Anterior band of inferior GH ligament
What portion of the joint capsule limits IR and posterior translation?
Posterior band of the inferior GH ligament
What portion of the joint capsule limits inferior translation and ER?
Superior GH ligament
What rib levels does the scapula typically run from?
2nd to 7th
What angle does the scapula sit in the coronal plane to provide the anteriorly facing fossa? (scaption plane)
30-45 degrees in the coronal plane
How many degrees of freedom does the SC joint have? What are they?
6 - protraction/retraction, depression/elevation, rotations
What ligament for the SC joint is most important for stability?
Posterior sternoclavicular ligament; loss in stability will result in A/P translation
What ligament runs from the superior surface of the first rib to the underside of the clavicle?
Costoclavicular ligament - major stabilizer of the SC joint
What two ligaments make up the coracoclavicular ligament?
Conoid: vertically runs between coracoid process and clavicle (elevation / protraction)
Trapezoid: superior/lateral direction between coracoid and clavicle (secondarily resists elevation / protraction)
What is the ratio of motion for GH mobility?
2 deg of GH motion -> 1 deg of scapular motion
Force couples: what opposes the RTC?
Deltoid - RTC depresses inferiorly, medially - deltoid produces line of force upward/outward
Force couples: what opposes the UT/levator scapulae?
Serratus anterior, lower trap; lower portion of serratus & LT contraction with UT/LS to create upward rotation
Upward rotation provides 4 crucial functions for the shoulder:
1) rotation of scapula provides optimal glenoid surface positioning
2) maintains efficient length tension relationship for deltoid
3) prevents subacromial impingement
4) provides stable scapular base to enable appropriate recruitment of scapulohumerla muscles
What group of muscles create inferior dynamic stability and concavity compression, esp in midranges?
Subscapularis (anterior) with infraspinatus/teres minor (posterior)
In Kibler slide/lateral slide test - what distance is considered abnormal for the border of the scapula to thoracic spine?
More than 1 to 1.5 cm - assessed in 3 positions; standing neutral, hands on hips, 90/90 abd/ER
What are the 3 pathological conditions for scapular position according to Kibler?
1) inferior angle; anterior tipping in sagittal plane - impingement with humeral pinch on acromion
2) medial border; displaced off thoracic wall due to IR of scapula - can be associated wtih GH instability
3) superior angle; early and excessive superior scapular elevation/shrug - RTC weakness with force couple imbalance
Type IV = normal scapulohumeral rhythm
Describe scapular assistance test:
Stabilizing clavicle and scapular spine while providing assistance for upward rotation - pos test if pt experiences less pain with assistance
Describe scapular retraction test:
Stabilize clavicle and scapular spine and press scapula against chest wall; if pt has less pain with empty can test then positive
What is the flip sign in referencing the scapula?
The medial border of the scapula flips away from the thorax and becomes more prominent - esp in resisted ER - serratus anterior/UT force couple disrupted
What area of the joint capsule becoming tight may lead to superior humeral head migration?
Posterior capsule - posteroinferior capsular tightness further inc contact of RTC as well as size of contact area
What motion is selectively lost in painful shoulders and overhead athletes?
IR
What are the two maneuvers for Apley’s scratch test?
IR and adduction (HBB) and ER and abduction (HBH)
What is the optimal MMT position for testing supraspinatus?
90 deg of elevation in scapular plane with thumb up (full can)
**Champagne toast position: 30 deg abd, 30 deg of flexion with slight ER
What is optimal MMT position for testing infraspinatus?
0 deg of elevation, 45 deg of IR from neutral (MMT position)
What is optimal MMT position for testing teres minor?
Patte test -> 90 deg of abduction, 90 deg of ER
What is optimal MMT position for subscapularis?
Gerber lift off position -> arm behind back
What tests need to be completed to clear the cervical spine and elbow as contribution to pain in the shoulder?
1) Spurlings (specific)
2) cervical AROM with overpressure
3) UCL/valgus test of elbow
4) Middle finger test for extensors
What type of impingement is as a result of excessive, repetitive contact between posterior aspect of the greater tuberosity and the glenoid border - esp when the arm is in extreme ranges of abd/ER?
Internal impingement
Where is internal impingement most often seen?
In overhead athletes, industrial workers
Structural changes the mechanically narrow the subacromial space (OA, bone spurs, small space) is what type of impingement?
Primary
What type of impingement is a disturbance in the functional centering of the humeral head with muscular imbalance, leading to abnormal displacement of the center of rotation in elevation (laxity, muscle weakness, excessive joint movement)?
Secondary
What ligament provides restraint to inferior translation with the arm adducted at the side?
Superior GH ligament
Name the special test - pt seated; one hand depresses scapula, other hand IR shoulder and then forces fwd flexion
Neers - Anterior pain = SAI
Posterior pain = internal impingement
Name the special test - pt seated; forced IR in the scapular plane with the arm elevated to 90 deg
Hawkins-Kennedy - provocation most likely SAI
Name the special test - pt seated; forced IR in sagittal plane (90 deg of fwd flexion)
Coracoid impingement test
Name the special test - pt seated; elevate arm to 90 deg of flexion, maximal horiz abduction and depress arm
Cross arm adduction test - more value in cluster testing - pain in AC joint
Name the special test - pt seated; active combination of elevation with IR (hand on opposite shoulder) - evaluates pt’s ability to control superior translation of humeral head
Yocum test - positive test is pain reproduced for SAI
What is the normal inferior translation during the sulcus test?
10 mm - tests superior GH ligament, coracohumeral ligament
What are normal values for the anterior and posterior drawer tests for the GH joint?
7.8 mm anteriorly - 7.9 mm posteriorly
Glide humerus anteromedial to posterolateral
During drawer testing; when the arm is positioned in different degrees of abduction - which aspect of the anterior capsule is being tested?
90 deg of abduction - testing inferior GH
30-60 deg of abduction - testing middle GH ligament
0-30 deg of abduction - testing superior GH ligament
What are the grades for anterior/posterior drawer testing?
Grade I - humeral translation is within glenoid rim
Grade II - humeral head over glenoid rim with spontaneous reduction
Grade III - translation of humeral head without reduction (must correlate with shoulder pain to dx instability)