Shoulder (Exam 4) Flashcards
____ joint has a lot of mobility and is unstable.
Glenohumeral
Repetitive overhead lifting. Stress and friction result from crowding and compression of RTC tendons under the subacromial arch.
Subacromical Rotator Cuff (RTC) Impingement
Compression primarily of supraspinatus tendon as pass under coracoacromial ligament between acromion and coracoid process.
Primary Impingement
GH instability creates reduced subacromial space because humeral head elevates.
Secondary Impingement
Degenerative changes decrease subacromial space. Bony osteophyte formation occupy space under anteroinferior surface of the acromion decreases space.
Other causes of Subacromial Rotator Cuff (RTC) Impingement
___ most commonly affected tendon in impingement. Just proximal to insertion on greater tuberosity is hypo vascular with repeated overhead arm motions, which compromise blood supply. “Critical Zone”.
Supraspinatus
Decrease overhead activity. Control pain and swelling (ice massage). Stretching (Posterior Shoulder Capsule). Strengthening (External Rotators, Scapular Stabilizers). Strengthen, Stabilize Scapulothoracic Musculature First. Address RTC Weakness Next (External Rotators).
Rehab of Primary and Secondary RTC Impingement
Performed in conjunction with RTC repair. Increases space and subacromial space.
Subacromial Depression for Impingement
Small RTC Tear
Less than 1 cm.
Medium RTC Tear
Less than 3 cm.
Large RTC Tear
Greater than 5 cm.
Active motion and pain-free exercise can begin as soon as patient tolerates.
Small Cuff Tears Rehab
Tissue protection must be longer to allow for healing. Splint 4-6 weeks.
Medium and Large Tears Rehab
If _____ allowed too early, healing compromised due to stress on repaired tissue.
Full ROM
Anterior Deltoid Fibers Resected
Open Procedure
Lateral Deltoid Fibers Splitting and Arthroscopic Decompression
Mini-Open Procedure
Longer To Heal
Larger Cuff Tears
Early or Acute Phase. 6 weeks. Codman’s (Pendulum) Exercises within first weeks to restore mobility and stimulate mechanoreceptors. With small tears - submax isometrics as tolerated. PROM - pulleys.
RTC Repair Rehab Phase 1
Intermediate Phase. 7-12 weeks. Progressive ROM with caution of repetitive shoulder abduction and forward flex above 90 degrees. Scapular stabilization exercises. Resistive theraband for progressive strengthening of RTC below 90 degrees.
RTC Repair Rehab Phase II
Minimum Protection Phase. Begins when increased motion without signs and improved strength. 13-21 weeks. Gradual return to normal activities.
RTC Repair Rehab Phase III
No AROM or active strengthening for 3-4 months. Immobilization is key. PROM with restrictions. Codman’s pendulum exercises and gentle AAROM may begin 3 months post op. Submax isometrics and scapular stabilization may be added cautiously 2-4 months after surgery. Full function and recovery may take 10 months.
Massive RTC Tears
____ most commonly dislocated joint. Men greater than women. Anterior greater than posterior. Result of indirect trauma.
Shoulder
With shoulder in Abd, Ext, ER.
Anterior
With shoulder in Abd, Flex, IR.
Posterior
Dislocations can be accompanied by.
RTC Tear, Glenoid Labrum Tear (Bankart Lesion), Compression or Impaction Fx (Hill-Sachs Lesion)
Avulsion of the capsule and glenoid labrum off anterior rim of glenoid resulting from traumatic anterior dislocation.
Glenoid Labrum Tear (Bankart Lesion)
Injury to posterolateral humeral head due to anterior shoulder instability. Does not cause the instability.
Compression or Impaction Fx (Hill-Sachs Lesion)
Immobilization avoid positions that may reproduce dislocation.
Non-Operative Managment
For anterior dislocation avoid.
Abduction, External Rotation
Reattach and tighten capsule using staple, suture, or thermal repair.
Anterior Shoulder Capsulorrhaphy
Move subscapularis from lesser to greater tuberosity.
Magnuson-Stack Procedure
Surgical repositioning of coracoid process, coracobrachialis, and short head biceps to GH neck.
Bristow Procedure
Slack in capsule is reduced. For patients with anterior instability.
Capsular Shift
Pain, decreased ROM, capsular inflammation, fibrous synovial adhesions. Females more than males. Typical 40-60 years old. Many are diabetic.
Adhesive Capsulitis “Frozen Shoulder”
Idiopathic and spontaneous. Most common.
Primary Adhesive Capsulitis
Post trauma or immobilization. In older patients, 1-2 days may be enough immobilization to cause adhesive capsulitis.
Secondary Adhesive Capsulitis
Slow onset of pain and decreased ROM. 6 weeks to 9 months.
Stage 1 Freezing Stage
Slow improvement in pain, but the stiffness remains. 4 months to 9 months.
Stage 2 Frozen Stage
Shoulder motion slowly returns to normal. 5 months to 24 months.
Stage 3 Thawing Stage
Frozen shoulder will generally get better on its own. Takes ___ to ____ years.
2-3
Pain control, restoring motion, function.
Treatment Adhesive Capsulitis
Pain free ROM, Codman’s (Pendulum), Wand and Pulley’s, Joint Mobs, Strengthening Scapular ROM, Stabilization, Submax Isometrics.
Treatment (Freezing Stage) Adhesive Capsulitis
Same as freezing stage, more aggressive stretching. Painful. Pulley’s, Wand, Dowel, Grade III, IV Joint Mobs, Strengthening.
Treatment (Later Stages) Adhesive Capsulitis
Partial tear of acromioclavicular ligaments. Joint tenderness. No joint instability or laxity. Minimal loss of function.
First Degree AC Sprain
Complete rupture acromioclavicular ligaments with partial tear coracoclavicular ligament. Moderate pain. Some dysfunction reduced shoulder abduction. Palpable gap between acromion and clavicle.
Second Degree AC Sprain
Dislocation between acromion and clavicle. Both AC and coracoclavicular ligaments ruptured. Distal clavicle displaced superiorly. Significant pain. Severe ROM limitation.
Third Degree AC Sprain
Shoulder harness or sling to approximate ligament for healing of torn ligaments. 3 - 6 weeks.
AC Sprain Treatment
Pins through AC to stabilize and approximate joint. Sutures around distal clavicle and coracoid process to stabilize. Screw between clavicle and coracoid. Excision of distal clavicle.
Severe Surgical Repair
Direct severe trauma. Significant injuries including humerus fx, pneumothorax, neuromuscular injuries.
Scapular Fractures
Treatment in conservative. Most common area of scapula to be fx. Immobilization with sling 2-3 weeks. Hand, wrist, elbow exercises allowed. PROM when pain and swelling subsides.
Scapular Body Fracture
Conservative symptomatic care with healing in 6 weeks
Extraarticular Glenoid Neck Fracture
Fx extends through glenoid fossa. Treatment depends on presence of GH instability as a result of the fx. No stability, immobilized in sling. Instability, surgical repair with screw inserted into fx fragments followed by immobilization.
Interarticular Glenoid Neck Fracture
Direct or indirect trauma. Generally men less than 25 years old.
Clavicle Fractures
Reduce fracture, maintain reduction minimized immobilization of GH joint.
Treatment for Clavicle Fractures
AROM for flexion. Limited to 40 degrees initially 4-6 weeks. Fx on distal end. Commonly fixated with ORIF because tend to be unstable and may have malunion.
Clavicle Fracture Treatment
AVN, OA, RA, Osteoporosis, Four Part Fracture of Proximal Humerus. If torn RTC needs repair as well, immobilization may last 6-8 weeks.
Total Shoulder Arthroplasty (TSA)
Deltoid contractions contraindicated when RTC repaired. No abduction. Gentle AAROM 1-2 days post op. Week 1 post op, active exercises elbow, wrist, hand. Pendulum exercises.
TSA Rehab Program
Traumatic onset.
Unidirectional anterior.
Bankart lesion, anterior inferior labral tear.
Surgery.
TUBS
Recurrent episodes of apprehension and/or anterior dislocations. Patient feels apprehension when UE is near position of subluxation/dislocation. Decreased abduction and ER. Muscle guarding in these positions.
TUBS
Stabilization exercise is beneficial in older patients. Surgery is indicated in younger patients.
TUBS Non-surgical Management
Avulsion of the anteroinferior glenohumeral ligament-labral complex from the anterior glenoid rim and scapular neck.
Bankart Lesion
The subscapularis insertion on the humeral head is detached to expose the glenohumeral ligaments. Glenohumeral ligaments are tightened. The labrum is reattached to the anterior glenoid with suture anchors. The capsule is tightened as subscapularis is reattached.
TUBS Surgical Procedure
The subscapularis does not become detached instead the subscapularis is tagged and held back by a suture. This is done mostly with overhead athletes.
Bankart Procedure
Atraumatic. Multidirectional. Bilateral Shoulder Findings. Rehab Appropriate Rx. Rarely Surgery. Inferior Capsular Shift If Surgery Performed.
AMBRI
Ligamentous laxity or muscle weakness. Chronic shoulder dislocations or subluxations with different motions. Abd/ER (Closed Pack) Flex, Add, IR (Posterior Humeral Head Translation)
AMBRI
Complaints of pain, apprehension, slipping, catching, clunking without history of dislocation. Repetitive micro trauma due to work or sports with/without underlying hyper mobility. Instability may develop in any direction.
Functional Instability
Pivotors
Scapular Stabilizers
Protectors
Rotator Cuff
Positioners
Deltoids, Latissimus Dorsi, Pectoralis Major, Pectoralis Minor
During glenohumeral movements with at least 90 degrees elevation, the scapular stabilizers must be strong enough to position the scapula correctly. Weak, scapulohumeral rhythm can be disrupted, causing impingement or other problems.
Pivoters Scapular Stabilizers
Serratus anterior, rhomboids, middle and lower trapezius. Serratus anterior and lower traps form important force couple that produces acromial elevation. Movement will be abnormal if the force couple is not working properly.
Lower Scapular Stabilizers
Tendinous band formed. Supraspinatus, Infraspinatus, Teres Minor, Subscapularis.
Protectors Rotator Cuff
Help keep the head of the humerus rotating against the glenoid fossa during joint motion. Compress and center the humeral head within the glenoid. Provide a counterforce to humeral head superior translation due to deltoid contraction.
Rotator Cuff
Faulty kinematics and muscle activation. Increased superior humeral head translation. Subsequent decrease is subacromial space which can lead to impingement.
Rotator Cuff Weakness
At 0 degrees abduction, IR assistance is given by pectoralis major, latissimus doors, and teres major. Less pectoralis major activity at 90 degrees abduction.
Subscapularis Exercises
Deltoids, Pectoralis Minor, Pectoralis Major, Latissimus Dorsi, Teres Major
Positioners
Provide dynamic stability within the scapular plane. Mid and post heads provide more stability by generating more compressive forces. During anterior shoulder instability, strengthen mid and post heads.
Deltoid
Moseley et al. group of 4 exercises make up the core of a scapular strengthening program.
Scaption, Rowing, Push-up with a plus, Press-Up.
Townsend et al. exercises considered challengeing.
Scaption with IR, Flexion, Horizontal Abd with ER, Press-Up.
Rowing
Trapezius, Levator Scapulae, Rhomboids
Horizontal Abd with ER
Trapezius, Levator Scapulae, Infraspinatus, Posterior/Medial Deltoid
Prone Arm Lift
Trapezius, Levator Scapulae, Infraspinatus, Posterior/Medial Deltoid, Supraspinatus
Dynamic Hug
Serratus Anterior, Subscapularis
Shoulder Shrug
Levator Scapulae, Upper Trapezius
Wall Slide
Upper Trapezius
Towel Slide
Rhomboids, Lower Trapezius
Press-Up
Pectoralis Major, Minor, Lat Dorsi
Push-Up with a Plus
Serratus Anterior
Ball Stability
Multi - RTC
Planar - Stabilizers
Inferior Glide
Serratus Anterior, Lower Trapezius
Low Row
Serratus Anterior, Lower Trapezius
Lawnmower
Serratus Anterior, Lower Trapezius
Robbery Exercise
Multi-Joint
CKC Exercises
Step-ups, Push-up, Stair-master, Slide board
RTC Muscles
Supraspinatus, Infraspinatus, Subscapularis, Teres Minor