Shoulder Complex Flashcards
Many problems for the shoulder can be related to ____.
age
RC degeneration/tears commonly occur in pts ___-____ years of age.
40-60
Primary impingement is seen in pts greater than ____ years old.
35
Secondary impingement is commonly seen in pts in their teens to _______.
early 20s
Chondrosarcomas usually occur in pts older than ____.
50
Calcium deposits may occur between ages ___-___.
20-40
Frozen shoulder is seen in pts ___-___ y/o if resulting from atraumatic origin.s
45-60
Kibler type: Inferior angle prominence, anterior tipping (commonly seen in pts with RC impingement).
Type I
Kibler type: Medial border scapula dysfunction; IR rotation of the scapula in the transverse plane; often seen in pts with GH instability.
Type II
Kibler type: Superior scapula dysfunction; involves early and excessive superior elevation during arm
Type III
Describe the normal movements of the scapula during elevation:
Scapular upward rotation, posterior tilting and ER.
Based on the pain symptoms, what is the likely cause?
Dull, toothache-like pain that is worse at night.
RC impairment
Based on the pain symptoms, what is the likely cause?
Hot, burning type pain
Calcific tendonitis
Based on the pain symptoms, what is the likely cause?
Numbness, tingling, shooting pain
Radiculopathy
Based on the pain symptoms, what is the likely cause?
Sharp, localized pain with elevation
RC impairment, impingement
Based on the pain symptoms, what is the likely cause?
Clunk, catch, click, sharp but subsiding
Labral impairment
List some red flags for shoulder impairment (10 total)
Age over 50
Night pain
Weight loss
Fever
Pain unrelated to activity
Pain not relieved by rest
Prior hx of cancer
Hx of smoking
Cardiac risk factors
Pleuritic pain
What does FHRSP stand for:
Forward head, rounded shoulder posture
Conditions and S/Sx to screen for include (6):
Non-mechanical pain
Cancer
Weight loss
Trauma
Neuro S/Sx
CVD/SOB
Primary scapular winging is a result of what?
Muscle weakness of scapular muscle stabilizers
Negative impact of primary scapular winging.
Disrupts normal muscle force couple balance of scapulothoracic complex.
Secondary scapular winging is a result of what?
An underlying pathology affecting the GH joint.
Dynamic scapular winging is caused by what?
A lesion to the long thoracic nerve (can also see with spinal accessory)
What does TUBS stand for?
Traumatic unilateral dislocations with a Bankart lesion requiring surgery.
What is the SPADI outcome measure?
Shoulder pain and disability index
What is the DASH outcome measure?
Disabilities of the arm shoulder and hand
5 things included in the observation portion of a shoulder exam.
Hands on hips
Symmetry of muscle tone
Swelling
Gait
Posture
What are the two most commonly involved rotator cuff muscles?
Supraspinatus
Infraspinatus
Increasing weakness with repeated contractions is termed ______.
Palsy
What range is considered normal laxity as a percentage?
0-25%
Describe grade I laxity and the percentage range:
A feeling of the humeral head riding up to the glenoid rim (25-50%).
Describe grade II laxity and the percentage range:
A feeling of the humeral head overriding the rim, but spontaneously reduces (>50%).
Describe grade III laxity and the percentage range:
A feeling of the humeral head overriding the rim, but remains dislocated (50%).
What is a hallmark sign of a rotator cuff pathology?
Weakness with elevation
RC Tendinopathy is usually caused by a ____________.
Repetitive mechanism / overuse (overhead activities)
Identify 3 symptoms of RC tendinopathy
Localized pain in Acromiohumeral space
May extend to lateral shoulder or elbow
Aggravated by elevation
___% of individuals who have RC tear are asymptomatic.
67
RC tear is similar to RC tendinopathy, but with greater ______________.
Loss of function
3 tests and measures for a RC pathology/tear.
Strength testing
Palpation
Special tests
Subacromial impingement syndrome may be cause by ________ or ________ of the structures occupying the acromiohumeral space.
Compression
Hypersensitivity
Subacromial impingement syndrome presents like ________, with positive impingement signs.
Tendinopathy
When subacromial impingement syndrome is caused by an anatomical predisposition, it’s termed _________.
Primary compressive disease.
Three things that can cause primary compressive disease:
Outlet stenosis
Hooked acromion
Bony spurring of the acromion
Primary impingement causes a _____ within the joint.
Lack of mobility
Secondary impingement causes ________ within the joint.
Reduced dynamic stability
Changes in the osteology of the joint causes _______.
Primary impingement
What is important to consider when testing for secondary impingement?
Similar to primary impingement tests, BUT must be looking at function and capacity of the RC and scapular stabilizers, as well as overall available mobility.
Identify 3 MOIs for Labral pathology
FOOSH
Extreme abduction
Forceful eccentric biceps contraction
2 S/S of labral pathology:
Clicking, popping, catching,
instability
Most common labral pathology
SLAP: superior labrum anterior (to) posterior
Type I SLAP:
Labral fraying (most common)
Type II SLAP:
Instability of labral-biceps complex (most common SLAP seen surgically)
An age over ___ is a red flag for shoulder impairment.
50
What cervical structures/conditions can refer pain to the shoulder (6)?
Nerve root
brachial plexus
supraclavicular nerves
facets
uncoverterbral joints
myelopathy.
The ___________ is an example of a cranial nerve that can refer pain to the shoulder.
Trigeminal nerve
This pathology in the thoracic region can refer pain to the shoulder.
Thoracic outlet syndrome
3 cardiovascular issues that can refer pain to the shoulder
Ischemia, aortic disease, MI
3 pulmonary issues that can refer pain to the shoulder
Upper lobe pneumonia
pulmonary embolism
pneumothorax
2 malignancies that can refer pain to the shoulder
Pancoast tumor
metastatic carcinoma
4 abdominal organs that can refer pain to the shoulder
Pancreas, liver, gallbladder, esophagus (GI)
The elbow may refer pain to the __________ shoulder
lateral
The wrist may refer pain to the __________ shoulder
lateral
The TMJ may refer pain to the ____, _____, and ____________
traps, pecs, lateral shoulder
functions of the rotator cuff
Forward flexion
Abduction
ER
IR
Stabilize head of humerus
During an overhand throwing/hitting motion, what is the role of the rotator cuff?
Decelerate the arm
What is the most common complaint of rotator cuff pathology?
Pain
_________ is more common under 40 years, _______ is more common over 40 years.
Tendinopathy; Tearing
In order to have a RC tear under 40 yrs, what event is generally required?
a macro-traumatic event
RC pathology may be thought of as a ________ disease.
degenerative
RC tendinopathy is usually brought on by a ________ mechanism
repetitive/overuse
What type of activities are more likely to result in RC tendinopathy?
Overhead activities
67% of individuals who have a RC tear are _________.
Asymptomatic
Outline the general protocol for RC repair and rehabilitation
Early PROM is stressed
Early ROM preferred in ER but not IR
Week 3-4 begin scapular strengthening (progress to AAROM)
Week 5-6 full PROM and AROM in all planes
By week 12 progress to max isokinetic exercise
SAIS stands for ____________.
Subacromial impingement syndrome
3 structures that might be compressed/hypersensitive in SAIS
Supraspinatus, LH of biceps tendon, subacromial bursa
SAIS presents like _________, with positive ___________ signs.
Tendinopathy; impingement signs
Identify three things that may cause SAIS
Outlet stenosis, hooked acromion, bony spurring of AC
PRIMARY impingement is due to:
lack of mobility within the joint from changes in osteology (i.e. hooked acromion)
Secondary impingement is due to:
Reduced dynamic stability. Head of humerus is not being held “snug” in glenoid fossa.
How are tests and measures different for secondary impingement compared to primary impingement?
Similar, but must be looking at function and capacity of the RC and scapular stabilizers as well as overall mobility.
3 mechanisms for a labral pathology:
FOOSH
Abducted arm
Forceful eccentric biceps contraction
Potential S/S of labral pathology (5)
Clicking, popping or catching
Instability
Positive anterior and/or posterior instability tests
Positive labrum tests
May also have positive LH biceps tendon tests
RC tears are more commonly seen in the NONDOMINANT/DOMINANT arm.
Dominant
What medical tests can help diagnose a SLAP tear?
MRI with contrast / arthrogram
General principles of labral pathology rehab(5):
Early protection of repair (limit abduction and/or ext. rotation.
Gradual return to normal AROM (stretching/joint mob.)
Strengthening focusing on RC
Neuromuscular re-ed.
Scapular musculature strengthening.
Type ___-___ SLAP will typically require surgical repair,
II-IV
S/P Labral rehab weeks 0-4
Gradually increase ER 10 deg. p/week, not to exceed 30 deg. by week 4. Scapular isometrics can begin early on.
S/P Labral rehab weeks 5-6
GH ROM is increased throughout, ER progresses to 50 degrees, active elbow flexion begins.
S/P Labral rehab weeks 7-12
Improve strength, balance RC and scap strength, by end of week 9 elevation is full and ER progressed to 90 deg. Week 10 submax isometrics.
With acceptable clinical exam able to begin overhead activities at 4 months post-op.
Avulsion of the anterior labrum from the rim of the glenoid is called a _______.
Bankart lesion
What symptom is present with a Bankart lesion?
Anterior instability
Those with a Bankart lesion may also have __________.
Hills-Sachs lesion
Impaction fracture on the posterior aspect of the humeral head.
Hills-Sachs lesion
Bankart lesion occurs in up to ___% of GH dislocations.
85%
Considered the gold standard for anterior instability:
Bankart procedure
Shoulder instability surgical interventions can be classified according to these:
Atraumatic (AMBRI)
Traumatic (TUBS)
AMBRI stands for:
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
TUBS stands for:
Traumatic
Unilateral
Bankart
Surgery
Main symptom associated with biceps tendinopathy
Anterior shoulder pain
phase of healing: -itis
acute
Phase of healing: -osis
Persistent. Load it!
typical MOI for traumatic shoulder instability:
Excessive force into ER while in 90 degrees of abduction.
What kind of dislocation is most common in a traumatic shoulder instability?
Anterior (inferior) dislocation
S/S: pain, apprehension with abduction, ER (90), weakness.
Traumatic shoulder instability
Traumatic shoulder instability management (4):
Rest
Manage acute edema/pain
RC strengthening and neuromuscular reeducation
Gradual return to activity
Altered scapular motion and position is termed ________.
Scapular dyskinesis
Scapular dyskinesis is more of a _________ than a diagnosis.
Symptom
AC joint pathology is associated with _______ and ________.
Traumatic sprains and dislocations
2 MOIs for AC joint pathology:
FOOSH, fall on tip of shoulder.
Calcific tendinitis is most common in _____________ tendon.
Supraspinatus
S/S: Acute pain/inflammation, then pain with movement through painful arc, radiographs show deposit.
Calcific tendinitis
Adhesive capsulitis stage I:
pain around GH joint, no stiffness
Adhesive capsulitis stage II:
Pain predominates; pain even with small movements
Adhesive capsulitis stage III:
Pain and stiffness; significant limitation of ROM
Adhesive capsulitis stage IV:
Stiff; little or no pain
T/F adhesive capsulitis eventually will resolve
True
Adhesive capsulitis is more common in FEMALES/MALES.
females
PT consideration for adhesive capsulitis pain phase:
DO NOT MOB
PT management in early phases of adhesive capsulitis:
Modalities to address pain
NSAIDS
There is an increased incidence AND poorer prognosis of adhesive capsulitis in patients with ____.
DM
Two characteristics of OA
Pain that is slowly progressive
Usually worse in a.m. and evening hours
Three interventions for hemiplegic shoulder:
Sling - alleviate positional pain
Strengthen RTC if possible
FES
Direct result of compression of the RC tendons b/t the humeral head and overlying anterior third of the acromion.
Primary compressive disease
Shoulder complex muscles that tend to be weak (3)
Serratus anterior
Mid/lower trapezius
Rhomboids
Shoulder muscles that tend to be strong (and/or tight) (3)
Upper trap
Lev scap
Pec minor and major
