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)
What capsular lesion is typically associated with positive subluxation/relocation test?
Posterior SLAP tear
When performing subluxation/relocation test, differentiate between anterior and posterior pain? (different diagnoses)
Anterior pain = secondary impingement
Posterior pain = internal impingement
Name the 9 items on the Beighton scale of hypermobility:
1) fwd bend
2) hyperextension of 5th MCP joint x2
3) thumb opposition to forearm x2
4) elbow hyperextension x2
5) knee hyperextension x2
Labral tears primarily occur in what aspect of the capsule?
Anterior-superior 60%,
posterior-superior 18%
anterior-inferior 1% (Bankart)
What lesion typically occurs with anterior dislocation?
Bankart lesion - detatchment from 2 to 6 o’clock R shoulder // 6 to 10 o’clock L shoulder
What are the four types of SLAP tear?
Type I: fraying of the superior labrum
Type II: (most prevalent) labrum & biceps detatchment from top of glenoid
Type III: bucket handle - torn labrum droops into joint - biceps intact
Type IV: bucket handle tear across top of labrum extending into biceps tendon
Loss of what anchor in the glenoid can lead to 100-120% inc in static stability load on the GH ligaments?
Biceps anchor
Describe the peel back mechanism for labral pathology?
Biceps anchor needs to decelerate extending elbow, esp in overhead throwers - torsional force created with abducted arm brought into maximal ER
Name the special test - pt supine; 90 deg of abduction, 90 deg of elbow flexion, compression through humerus while circumducting arm
Circumduction test - clicking or catching pain or reproduction of sxs
Name the special test - pt supine; 90-120 deg abd, 90 deg ER, slight anterior glide of humeral head while rotating between IR/ER with humeral head compression
Clunk test - feeling for clunk
Name the special test - pt seated; have pt flex arm to 90 deg, IR arm and resisted downward pressure - then - reassess in forearm supination
O’Brien Active Compression test - positive if have pain in position 1 which is decreased/diminished in position 2
Name the special test - pt seated; arm in 90/90 position, one hand stabilizing shoulder and then have pt pronate to supinate
Mimori - positive if pronation produces pain, supination alleviates pain
Name the special test - pt supine; arm abducted to 90 deg, resist biceps - arm abducted to 120 deg, resist biceps
Biceps load test 1 and 2 - positive if complains of subjective pain during biceps testing
Name the special test - pt supine; shoulder to 90 deg abd, 60-70 deg of ER, neutral forearm - passively ER shoulder while resisting supination
ER supination test - positive test is discomfort in the shoulder
In an AP radiograph, what distance is considered indicative of subluxation/dislocation?
> 7-8 mm of distance between acromion & humeral head
What lesion occurs during an anterior dislocation? (posterior humeral head on anterior glenoid rim)
Hill-Sachs lesion
What is a reverse Hill-Sachs lesion?
Occurs during posterior dislocation - anterior humeral head on posterior glenoid rim
Radiographs of the shoulder can identify what diagnoses?
1) fractures
2) calcification of supraspinatus
3) irregularity of greater tuberosity
4) sclerosis of undersurface acromion
5) elevated humeral head (RTC tendinopathy)
What is the preferred diagnostic test for subtle or complex fractures in the shoulder?
CT scan
Why is dye injected into a joint during an MRI?
Dye distends the joint which separates structures with contrast
What is the typical strength ER/IR ratio?
66% - low ER/IR ratio due to atrophy of ERs
Overhead athletes suggested to be >75%
What ROM for elevation derives peak forces against the acromion?
85-135 deg of flexion
Name the three stages of primary impingement according to Neer:
Stage I: edema and hemorrhage - mechanical irritation
Stage II: fibrosis and tendonitis - repeated episodes of mechanical inflammation, thickening fibrosis of subacromial bursa
Stage III: bone spurs, tendon rupture - full thickness tears, biceps lesion, bony alteration of AC joint
What are the types/shapes of the AC joint?
Type I: flat
Type II: curved
Type III; hooked - 70% associated full thickness RTC tears
What form of impingement results from underlying instability of the GH joint (instability, laxity, loss of dynamic muscular control)?
Secondary impingement
At what percentage of damage does tendon failure occur?
30% or more - normal healthy tendons do no tear
What impingement occurs with compression of the supra/infraspinatus tendons on the posterior aspect of the glenoid rim?
Internal - posterior impingement
Which position of the shoulder blade decreases the subacromial space?
Protraction
During the posterior load & shift/posterior drawer assessment, what percentage of posterior shift is normal for the GH joint on glenoid?
50% - >50% and pain/reproduction of sxs is positive test
What is the optimal position to stretch the posterior joint capsule?
90 deg of abduction, 30 deg of elevation in scapular plane and IR
What are three benefits of using a towel with ER strengthening?
1) improves ER activation by 10%
2) facilitates adduction isometric activation to enhance subacromial space
3) reduces ‘wringing out’ phenomena
What percentage of MVIC for ER does not elicit deltoid activation during ER strengthening?
40%
Partial thickness tears on the superior/bursal side are the result of what type of impingement?
Primary & secondary - compressive, macrotrauma
Partial thickness tears on the inferior/articular side are the result of what type of impingement?
Internal - overhead athletes with anterior instability, capsular & labral insufficiency, muscular imbalance
What are the classification of RTC tear sizes?
Small < 1 cm
Medium between 1-3 cm
Large 3-5 cm
Massive > 5 cm
Which type of repair - single or double row - appears to be slightly closer to reapproximation of total geometry of RTC foot print?
Double row - allows for more physiologic area of contact - theoretical inc in healing potential and tensile strength
With early PROM for a RTC repair, what motion is limited due to the strain placed on the supraspinatus?
IR especially at 30-60 deg
What are pre-surgical factors that may result in post-surgical stiffness for a RTC?
1) calcific tendonitis
2) partial articular supraspinatus tendon avulsion
3) concurrent SLAP repair
4) preop adhesive capsulitis
5) single tendon RTC repair
What position for strengthening supraspinatus results in poor and disappointing results practically and clinically?
Empty can strengthening
What muscle group blends into the GH ligaments and joint capsule?
RTC - provides dynamic ligamentous tension for shoulder instability
What position of the shoulder provides maximal bony congruency for strengthening?
Scapular plane with 30-45 deg anterior to coronal plane
Where is the highest rate of instability for the GH joint noted?
Anteriorly -> posteriorly -> multi-directionally
What position is the ‘low tension’ zone for initial PROM for surgical repair of the joint capsule?
PROM with arm at side between 30-45 deg of ER
What surgery is the standard for anterior dislocation?
Bankart reconstruction - restores tension in anteriorinferior capsule and inferior GH ligament complex; abrade glenoid rim to promote healing
What are the four types of SLAP repair?
1) Type I: debridement
2) Type II: biceps anchor attachment
3) Type III: debridement of bucket handle tear
4) Type IV: biceps anchor (tenodesis/tenotomy) with debridement of bucket handle tear
What is the most common type of SLAP tear & repair/
Type II
What is the common progression for ER passively with SLAP repairs?
10 deg per week, not to exceed 30 deg by week 4 (done in 45 deg of abduction or less) with progression ER to 90 deg of abduction until at least 6 weeks
What are the two stabilizing ligaments for the AC joint?
Acromioclavicular ligament - AP stabilization Coracoclavicular ligament (conoid/trapezoid) vertical stability
What are the six classifications of AC joint separation?
1) sprain of AC ligament
2) AC ligament and capsule ruptured, not CC ligament
3)complete rupture of AC/CC ligaments
4-6)rupture of AC, CC ligaments with inc deg of soft tissue trauma/clavicular displacement
What ROM places additional stress on the AC joint?
Horizontal adduction - end range flexion / extension
What are common comorbid factors for frozen shoulder?
Diabetes, thyroid disease, 40-65 y.o, female > male
During frozen shoulder, what aspect of the capsuloligamentous complex becomes contracted?
Rotator cuff interval - anterior supraspinatus, upper subscapularis border with the superior GH ligament - coracohumeral ligament
What are the phases of frozen shoulder?
3-4 defined phases:
1) pre-adhesive (3 months) - sharp pain at end range, pain at rest (distinct loss of ER)
2) adhesive/freezing (3-9 months) acute discomfort, painful EROM
3) frozen/fibrotic (9-15 months) mature capsuloligamentous fibrosis, significant stiffness, less pain
4) thawing (15-24 months) painless stiffness, motion typically improves over time
What is the hallmark sign of adhesive capsulitis?
ER loss > 50% uninvolved shoulder, less than 30 deg of ER - can have significant loss of IR > than abduction
What is the shoulder capsular pattern?
Loss of ER > abduction > IR - adhesive capsulitis doesn’t necessarily follow capsular pattern
What are the three types of secondary adhesive capsulitis?
1) systemic (diabetes, thyroid)
2) extrinsic (CVA, myocardial infarction, COPD, distal extremity failure)
3) intrinsic (RTC/biceps tendinopathy, calcific tendonitis, GH joint arthropathy, humeral fracture)
What is the cause of primary adhesive capsulitis?
No association with systmetic disease/condition - idiopathic
What grades of joint mobilization are more effective for adhesive capsulitis?
Lower grades just as effective
What does TERT stand for?
Total end range time; shorter holds = more frequency
longer holds = short frequency
What are the three most commonly affected large joints for arthroplasty? (in affected order)
Hip, knee, shoulder
Difference between primary // secondary OA?
Primary = no identifiable cause Secondary = traumatic, postsurgical
What shoulder surgery has better outcomes for OA?
Total shoulder arthroplasty vs. hemiarthroplasty
What surgery does late state RA require due to bone loss or humeral head migration?
Hemiarthroplasty or reverse TSA
With acute fracture, esp 3/4 part fractures, what surgery does this shoulder typically undergo?
With sparing of glenoid, usually hemiarthroplasty
What muscle is released during a TSA?
Subscapularis
What condition must be met to perform a hemiarthroplasty?
The glenoid must be intact
What happens to the long head of the biceps during TSA?
Tenodesed or tenotomy
When is a reverse total shoulder arthroplasty indicated?
1) massive or irreparable RTC
2) proximal humerus fracture with deficient RTC
3) revision of previous TSA with concurrent RTC deficiency
What motions need to be avoided with therapy treatment for a reverse total shoulder?
Extension, adduction - avoid ER in frontal plane because of instability
