Shoulder Flashcards
Posterior drawer test/Posterior load and shift test
- Position
- Mistakes with testing
Position: 90 deg abd in scapular plane
Mistakes: testing in coronal plane and direct posterior glide instead of posterolateral motion
Testing IR passively
- Position
Coronal plane in supine with posterior translation along coracoid (anterior aspect) and shoulder
IR ROM stretching position for high posterior capsule strain
30 deg shoulder elevation in scapular plane (scaption)
6 types of synovial joints
- Pivot 2. Ball and Socket 3. Plane 4. Hinge 5. Condyloid 6. Saddle
AC joint ligaments (3)
- Acromioclavicular 2. Coracoacromial 3. Coracoclavicular (conoid, trapezoid)
Glenohumeral ligaments (3)
- Superior 2. Middle 3. Inferior
Pectoral region muscles (4)
Pectoralis major and minor, serratus anterior, subclavius
Pec major
A, F, I
Attachment: anterior medial half of clavicle; sternum, costal cartilages of ribs 1-6; anterior layer of rectus sheath; greater tubercle of humerus
Innervation: lateral pectoral n. to clavicular head (C5-7); medial pectoral n. to sternal head (C8, T1)
Subcalvius
A, F, I, AS
A: clavicle subclavian groove; origin: first rib
F: depression of clavicle elevation, elevation of 1st rib
I: subclavian n.
AS: thoracoacomial trunk, clavicular branch
Serratus Anterior
A, F, I, AS
A: 2nd<>9th ribs (origin) costal aspect of medial margin of scapula (insertion)
F: protracts/stabilizes scapula, assist with upward rotation
I: long thoracic n. (C5-C7)
AS: lateral thoracic a., superior thoracic a. (upper part), thoracodorsal a. (lower part)
Upper brachial plexus injury MOIs and presentation
MOIs: 1. birthing traction on neck 2. fall on neck
Presentation: dislocated look of shoulder
Lower brachial plexus injury MOIs and presentation
MOIs: 1. hanging from branch/ladder with a fall 2. birthing traction on baby’s arm; claw hand with radial n. finger extension deficit
Sections of brachial plexus
Roots, Trunks, Divisions, Cords, Terminal branches
Dorsal scapular n.
- root(s)
- innervates
- C5
- Rhomboids and levator scapulae muscles
Long thoracic n.
- root(s)
- innervates
- C5-7
- SA muscle
Suprascapular n.
- root(s)
- direction/location
- innervates
- C5-6
- passes through scapular notch
- supraspinatus, infrapsinatus, and shoulder joint
N. to the subclavius
roots
innervates
- C5-6
- Subclavius and slips to SCJ
Median n. branches in arm? muscles innervated (general) cutaneous innervation area entrapment?
No branches in arm
Forearm and hand muscles
cutaneous distribution in hand
Commonly entrapped
Upper lesions of brachial plexus dx name roots involved nerves involved presentation
Dx: Erb-Duchenne Palsy “waiter’s tip”
Roots: C5-6 torn
Nerves affected/involved: suprascapular n., musculocutaneous n., axillary n.
Presentation: atrophy of deltoid and biceps br. and medially rotated (IR) arm
Lower brachial plexus injury dx name roots involved nerves involved presentation (and why)
Dx: Klumpke palsy
Roots: C8, T1 torn
Nerves involved: Median and ulnar n’s.
Claw like hand
- lumbrical muscle and interosseous muscle dysfunction
- forearm extensors and flexors unopposed
Winged scapular - peripheral n. damage
- which nerve?
Long thoracic n. => SA inhibition/dysfunction
Wrist drop - peripheral n./brachial plexus damage
Radial n. => forearm extensor force production (posterior compartment of forearm)
Saturday Night Syndrome - what is it? what nerves/structures involved?
compression injury of brachial plexus with potential axillary artery/vein occlusion => ischemia
Pectoralis minor
A, F, I, AS
attachment: 3rd-5th ribs to medial border and superior surface of the coracoid process of the scapula
function: stabilizes scapular - protracts scapular, rib elevation with inspiration
innervation: medial pectoral n. (C8)
arterial supply: pectoral br. of the thoracoacromial tr.
Types of ACJ injuries: 6 types including structures involved
- AC sprain w/o tear.
- AC ligament and capsule are ruptured
- Complete AC and CC ligaments ruptures - “step off deformity”
4-6. similar to type 3 with increasing soft tissue trauma and clavicular displacement.
Shoulder motions that place increased stress on ACJ
IR behind the back
horizontal adduction
end-range flexion and extension
MOI for ACJ injuries
- common types
- common activities leading to injury(ies)
direct blow or fall on shoulder w/ adduction
football, hockey, skiing, snowboarding, and bicycling
**common in football athletes with shoulder injuries
Ligaments of the ACJ
Coracoclavicular ligament complex (conoid and trapezoid) and acromioclavicular ligament
Acromioclavicular ligament function
stabilization of ACJ in AP plane
Coracoclavicular ligament complex (conoid and trapezoid) function
+ conoid restricts what?
majority of vertical stability
conoid ligament: restricts superior and anterior translation and superior and anterior rotation of the clavicle
Motion that places greatest strain on coracoclavicular ligament (conoid and trapezoid)
Shoulder extension
Two common/safest surgical interventions for ACJ repair
Tightrope and end button closed loop
- both use drilled holes with buttons through coracoid and acromion.
- allograft or autograft
standard bracing for ACJ repair for how long
Platform bracing for 6-8 weeks
Four points of conservative rehabilitation for Type 1-3 ACJ injuries
Short term immobilization
Medication for symptom relief
Progressive ROM
Strengthening
Frozen shoulder/Adhesive capsulitis: percentage of population affected increased risk populations common age group(s) odds of second shoulder being affected in presence of one side
2-5% of population affected
11-38% likelihood with pts with thyroid dz and DM
40-65 years old
females more than males
increased risk of 2nd shoulder experiencing FS (5-34%, 14% chance of B shoulders at once/same time
What is the Rotator Cuff Interval?
RCI = anterior edge of supraspinatus, superior aspect of superior glenohumeral ligament, superolateral border of subscapularis and deep surface of coracohumeral ligament
Areas of shoulder to focus on mobilizing with FS/adhesive capsulitis
GH capsuloligamentous complex and rotator cuff interval
What are the four stages of FS per Neviaser and Neviaser?
- Pre-adhesive stage - painful (commonly misdx’d as RC impingement
- Acute adhesive stage (Freezing) - thickened red synovitis; 3-9 month period; highly painful
- Fibrotic stage (Frozen) - 12-15 months after onset; significant stiffness, less pain
- Thawing stage - painless stiffness; remodeling leads to improved motion by 15-24 months
Diagnosis of FS
> 25% loss of ROM in IR, flexion, and abduction with >50% ER PROM compared to contralateral side or <30 deg ER on affecte side with PROM
* most RC impingement won’t show the significant ER loss present with FS
FS: idiopathic vs primary
Are the same
Three types of secondary FS
- Systemic (i.e. DM, thyroid dz)
- Extrinsic (i.e. w/ CVA, MI, COPD, CDD, distal extremity failure)
- Intrinsic (RC tendinopathy, biceps tendinopathy, CJ or GHJ athropathy)
What is the irritability level classification?
System used to assess pt pain, assisting with relative grading of present pain (particularly useful for FS monitoring)
Dosage of “stretching” for pt’s with FS are (2)
- Stage of FS
2. Irritability classification
What is TERT?
Total end-range time = Frequency x Duration of time at end-range motion
When stretching the capsuloligamentous complex, how should it be visualized?
with the circle concept
