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Musckuloskeletal > Shoulder Impairments part 1 > Flashcards

Shoulder Impairments part 1 Flashcards

1
Q

4 joints in the shoulder

A
  • Scapulothoracic
  • Sternoclavicular
  • Acromioclavicular
  • Glenohumeral
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2
Q

Scapulothoracic joint

A
  • Not a “true joint” Floats on posterior thoracic wall.
  • Only true bony attachment is the acromioclavicular joint
  • Protraction, retraction, elevation, depression, upward rotation and downward rotation.
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3
Q

Sternoclavicular joint

A
  • Only bony attachment between the upper limb and the axial skeleton
  • lacks bony stability
  • Stability achieved by capsuloligamentous restraints and the disc
  • The ligaments that provide this stability are the anterior SC ligament, posterior SC ligament, interclavicular and costoclavicular ligaments.
  • typically dislocated anteriorly but can happen posteriorly (
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4
Q

AC joint

A
  • lots of issues with the AC joint
  • often gets hot spots, can get arthritis on it. Especially in contact sports.
  • With injury to these ligaments- we see the end of the clavicle rises higher. One will be higher than the other and will see a gap with subluxation.
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5
Q

Rhythm of the scapula

A
  • 2:1 ration overall (glenohumeral: scapulothoracic)
  • During the first 60 degrees of flexion or the initial 30 degrees of abduction, the scapula does not move much and is seeking a position of stability in relation to the humerus (setting phase)
  • During this setting phase the GH joint is the primary contributor to movement.
  • With increasing range of motion, the scapula increases its contribution to motion and the scapulohumeral ratio may approach 1:1 during this time.
  • If the scapula isn’t moving then we have to do work on it.
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6
Q

Glenohumeral joint

A
  • Articular surface
  • Synovial ball and socket articulation

Joint stability is provided by:
=rotator cuff
=long head of biceps brachii
=extracapsular ligaments

  • the labrum deepens the socket and gives some stability to the joint. If torn the head will pop in and out.
  • shoulder dislocation is a result of ligament laxivity or ligament tears.
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7
Q

Rotator cuff muscles

A
  • Supraspinatus
  • most commonly torn ligament in the rotator cuff- highly susceptible to injury and to being pinched.
  • Infraspinatus
  • is the second most common pinched or torn rotator cuff muscle.
  • Teres minor
  • Subscapularis
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8
Q

Supraspinatus

A
  • initiates abduction
  • It is the anchor of the shoulder
  • Deltoid is a big and powerful muscle and the direction of pull is right into the acromion- if not balanced by the supraspinatus it would shove up into the acromion.
  • If torn, cannot reach over the head. Cant go beyond 90 degrees and starts to pinch at 60 degrees.
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9
Q

force couple

A
  • muscles with opposite actions that work together to produce rotation.
  • 2 force couples in the shoulder. (upper and lower trap-external rotation, supraspinatus and deltoid are both force couples)
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10
Q

Shoulder impingement

A
  • An umbrella term in that includes any pathological change which occurs under the coracoacromial arch including rotator cuff tears and describes several degrees of muscle injury from compression or tears that result from impingement.
  • Mechanism of injury is usually gradual onset, history of overuse, especially overhead activity.

Impinged or pinched?- supraspinatus or long head of the biceps.

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11
Q

Shoulder impingement structures

A
  • Suprapinatus
  • Long head of the biceps
  • The subacromial bursae- bursitis, highly innervated, hurt when get inflamed
  • On occasion the infraspinatus
  • The labrum and joint capsule (internal impingement)
  • —–Structures on underside of joint labrum and capsule can get pinched.
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12
Q

impingement of bursa

A

the bursa is highly innervated

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13
Q

Biceps impingement

A

inflammation occurs where biceps tendon passes through bicipital groove and over the head of the humerus, just like a rope through a pulley.

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14
Q

Causes of impingement

A
  • Instability of the glenohumeral joint: weakness, capsule and joint laxity
  • Dyskinesia (scapula not moving in correct rhythm with humeral head)
  • Poor posture
  • Arthritis- can get uneven surfaces- bumps on it, grows osteophytes going down off of the acromion and stick into the subacromial space and get a little dagger into the supraspinatus. Don’t want to be doing resistance overhead exercises (just need to be functional overhead)
  • Anatomical predisposition.
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15
Q

External and Internal impingement

A

External impingement: Rotator cuff and/or bursae are getting compressed or pinched on the superior surface by the acromion.

Internal Impingement- The rotator cuff, labrum, or capsule is getting compressed or pinched on the under surface by the humeral head.

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16
Q

Anatomical Acromion types

A

-Another thing that can make someone susceptible to impingement. The size, shapes, and tilt of the acromion- a persons anatomical make up can contribute.

Type 1- a lot of room

Type 2- Most of us are a type 2 acromion

Type 3- Has a sharp arch- will be very very susceptible to shoulder impingement.

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17
Q

forward head and rounded shoulders

A

-external rhomboids, serratus, and upper trap, levator scapula, and stretch pec minor

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18
Q

Dyskinesia

A

-Muscles of the scapula are not working together either from muscle imbalance or neurological motor planning impairment

SICK scapula

  • Scapular malposition
  • Inferior medial border prominence
  • Coracoid pain and malposition
  • Dyskinesis of scapular motion
19
Q

Medical Diagnosis: Diagnositcs

A

X-ray- look for arthritis, type of acromion, bone wear and tear, dislocation.

MRI- identification of soft tissue structures

MRI with Gadolineum Dye- better image and shows leak in capsule and ligamentous structures

20
Q

Medical OT examination

A

-Patient history
-Clinical observations including watching scapular motion
-ROM
-MMT
Special Tests/provocation tests- a whole lot of them.

21
Q

Painful Arc

A

When in the arc of motion does pain occur for abduction and flexion, where does it start to hurt.

22
Q

Hawkins Kennedy Test

A

Looks at the supraspinatus- sit on matt stabilize shoulder, internally rotate with flexed elbow and shoulder at 90. hold where you arm is at and dont let me move you- push on upper arm. If it hurts in front of a shoulder it is a positive test.

SUPRASPINATUS

-Have them raise arm to 90 and the flex elbow with arm in internal rotation. Stabilize shoulder and then push down. Not going to push hard (just get them to contract). Positive sign would be pain in the anterior shoulder., pain not in the anterior shoulder is still good information to know bout would be negative if not in the anterior shoulder. Do both sides.c

23
Q

Neer Test

A

Neer test- make sure their feet can touch the floor, fully internally rotate arm at 90, push down and depress her shoulder while placing her into flexion- if it is painful it is a positive Neer sign (test both sides). Take into full range for flexion or until it is uncomfortable for them (a positive test). Rotator cuff, long head of the biceps, and the bursa can all get impinged.

These tests are provocative- will show shoulder impingement or rotator cuff tear.

Cannot get someone with frozen shoulder into a new position for the Neer test- may be able to get the Hawkins
- Best thing to measure= posture, ROM, scapular mobility, etc.

24
Q

Full can/Empty can test

A

Also known as Jobes test

Empty can or full can test- empty can test hurts worse so start with the full can.

Come up into a scapular plane (open packed position) stabilize at shoulder, have hand positioned to grab full can position, push down near the wrist. Empty can is with the wrist pronated and arm internally rotated.

Always start with the full can first. Flex at 90 in the scapular plane, give resistance just distal to the elbow joint, push down enough to get her to contract to see if they have any pain, if positive it is up near the shoulder (anterior). Do both sides

  • that is the full can
  • this can look at the biceps as well, slap lesion

Empty can-
Arm flexed to 90 in scapular plane in internal rotation- hold don’t let me move you, pain at anterior deltoid is a positive sign.

25
Q

Drop Arm Test

A

-Patient in abduction with shoulder supported and have them slowly bring their arm back down. With a rotator cuff tear they will not be able to control bringing their arm down. Also want to palpate the shoulder.

*Palpate the acromion, the bicipital long head, scapular motion, supraspinatus at the greater tubercle, feel around to see if there is anything incomfortable, pec minor tightness, winging?,
Palpation counts as an assessment as long as you look at everything involved

Tests for a torn rotator cuff. – may warrant a further assessment.

26
Q

Bicep Impingement

A

Yergensons”
-posture, check for biceps tendon first (feel under your thumb) thumb is palpating while doing this test, looking that the biceps stays in the bicipital grove with resisting her to supinate. Flex elbow to 90 and go into full pronation, hold her there and try and turn palm up into the ceiling while you hold in place. Feel the bicipital tendon.

Speeds Test:
-Sitting is preferential in a chair with back support.

Come into full external rotation and supination, have them come into about 30 degrees of flexion, just distal to the elbow joint line and push, don’t let me move you, positive sign is yes I have pain at the bicipital grove.

27
Q

chances of tear

A

Symptoms

  • Weak external rotation
  • Weak supraspinatus
  • Positive impingement sign
  • difficulty sleeping on affected side (increases chances of a rotator cuff tear)

Chance of tear:

  • 3/3 symptoms= 98% chance of rotator cuff tear
  • People over 60 2/3= 98% chance of a tear
28
Q

Rotator Cuff Tear

A

Will see rotator cuff tears if work in UE outpatient. Heavy overhead lifting is an issue and trying can lead to increased problems.

29
Q

Conservative treatment of rotator cuff tear

A
  • ice 15-20 min
  • NSAIDS
  • cortisone injection
  • sleep with pillow under affected arm- sleep in open packed position, should not sleep on affected side.
  • Pendulums- table as support because on medication (can be dizzy)
  • Strengthening below 90
  • Improve posture (modified doorway stretches, foam roller)
  • Soft tissue mobilization

*keep things below 90 in everything that they do

30
Q

Pain free motion

A
  • perform motions in a scapular plane (both passive and active)
  • Save pure abduction with all clients until later when they are pain free. Abduction is a provocative motion for pain.
31
Q

Exercises- rotator cuff

A
  • correct posture and restore balance

- Scapular ROM and strengthening (hand walks), Is, Ys, Ts, pulling weeds, push up plus, tree hugs

32
Q

Exercises for impingement

A

-Keep shoulders below 90 degrees during exercises and ADLs

  • Pendulums
  • TheraBand internal rotation, external rotation, and extension

pain free wall slides.

33
Q

Subacromial decompression

A

surgical option for shoulder impingement

  • make more room for the cuff, biceps, and bursa
  • these patients don’t have the precautions afterwards, no repair then they can do a lot of ranging and motion.
34
Q

Post subacromial Decompression

A

Therapy:
Ice, IFC, AAROM, AROM, isometrics progressing to strengthening

*no ROM precautions since nothing was repaired.

35
Q

Rotator Cuff tear: surgery

A

-May or may not require surgery

Follow post surgery protocol

  • usually 6 weeks in immobilizer (8 for large tears) only passive motion allowed
  • no active movement during this time except for pendulums
  • PROM with restrictions
  • Week 6-12 AAROM and AROM (no strengthening) motion only
  • Strengthening starts at week 12

*no sleeping on shoulder until week 12

36
Q

Codman’s Hike

A
  • individuals with shoulder pain or weakness tend to try to lift the shoulder using the shoulder girdle and trunk muscles when reaching overhead.
  • we want to prevent this from happening.
  • Use upper trap and levator to try and get arm over head and start to develop the hike.

Have to work on strengthening what they have first and then help cue them to depress shoulder when they start to hike shoulder.

37
Q

Shoulder Instability

A

Traumatic Instability: TUBS

  • Anterior instability
  • Posterior instability
  • Superior instability
  • Multidirectional
  • means loose ligaments are at risk for dislocation
38
Q

Shoulder dislocation

A
  • Shoulder comes out of the glenoid fossa
  • May spontaneously go back in place or require reduction
  • Risk for recurrent dislocation secondary to stretching out of labrum and capsule or possible tear to the labrum.
  • Positive apprehension sign (pain with abduction and external rotation at 90 degrees)

*Keep motion in a diamond- keep motion out front until structures are strengthened to keep from popping out.

39
Q

Labral repair

A

Go in and tighten the ligaments through surgery. Often results in stiffness, but stiffness is better than being loose in the shoulder.

40
Q

Axial load test

A

Have the patient lay down on their back in supine. Make sure the pillow is out of the way because it blocks their motion. Shoulder is abducted 90 and the elbow is bent. Push in and internally and externally rotate. If it is painful it is a positive test.

41
Q

Anterior shift test

A

How much translation or movement you can get in the humeral head forward.
-posture, grab ahold of humeral head and see if you can push her forward. Pushing forward to see if they translate. When accompanied with pain then it may be something that we want to take a look at. Can get a posterior labral tears as well but are less frequent.

42
Q

Trigger of SLAP lesions

A

-Yergenson’s can also be used

43
Q

Intervention: later stage

A

Theraband- Cando is a little more affordable (may snap easier). Yellow, red, green, blue, black, (easy to hard)
Typically start with yellow or red
Internal and external rotation with the theraband. (towel roll under their arm between body and the arm). GOOD POSTURE!!!!
Watch for supstitutions (wrist flexion or extension). Twist body
Rows- pillar or stair rail, support pole- pull down and back(chest will comeout)
Extension of the hip facilitates retraction of the shoulder.

Is, Ys, Ts, and pulling wings- prone scapular stabilizing exercise
Working on muscles that stabilize the scapula, doesn’t help with timing.
Is- on stomach bring arm back in line with body- into extension
Ys- bring arm into flexion
Ts- out to the side
Pulling weeds- rhomboids. (black burn prone)

Musckuloskeletal (14 decks)

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