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PTMMD > Shoulder Impingement, Biomechanics/Scapular Dyskinesia, Nerve Entrapment and Fractures > Flashcards

Shoulder Impingement, Biomechanics/Scapular Dyskinesia, Nerve Entrapment and Fractures Flashcards

1
Q

What are 2 types of shoulder Impingements?

A
  • External Impingement
  • Internal Impingement
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2
Q

What is External Impingement?

A

The common impingement at the glenohumeral joint causing compression of soft tissues between the greater tuberosity and the coraco-acromial arch

Characterized by a decrease in subacromial space and a ‘painful arc’ of motion.

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3
Q

What causes external impingement?

A

A decrease in the amount of subacromial space leading to early contact of the humerus with the coraco-acromial arch

This results in compression of the soft tissues.

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4
Q

What are the classic findings of external impingement?

A

A ‘painful arc’ of motion with greatest pain beyond 90 degrees of abduction

Pain is located along the anterior-lateral side of the shoulder.

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5
Q

What is internal impingement?

A

Entrapment of soft tissues between the head of the humerus and the glenoid labrum complex

Involves the joint capsule, infraspinatus, and supraspinatus.

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6
Q

Who is most commonly affected by internal impingement?

A

Overhead athletes

This population is particularly vulnerable due to their range of motion requirements.

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7
Q

What is the mechanism of injury (MOI) for internal impingement?

A

Abduction and external rotation of the humerus greater than 90 degrees

This position can pinch the posterior joint capsule and/or infraspinatus/supraspinatus.

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8
Q

Where is the pain located in cases of internal impingement?

A

In the posterior aspect of the shoulder

Pain is greatest towards end-range external rotation.

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9
Q

What is the normal position of the scapula?

A
  • Lateral border of the scapula is angled anterior 30-45° from the frontal plane
  • Upwardly rotated scapula of ~10-20°
  • Anterior Tipping of ~10-20°
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10
Q

With the Deltoid and RTC force couple, what happens if the strength ratio of the deltoids are greater than the RTC?

A

It would result in an upward/superior migration of the humeral head during arm movements, thereby causing pathological compression of the greater tuberosity of the humerus into the underside of the coraco-acromial arch

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11
Q

What is the role of the Upper Trapezius and Serratus Anterior in shoulder complex elevation?

A

They create an upward rotation of the scapula

This occurs due to the contractile pull of these scapula-thoracic muscles.

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12
Q

List the four functions of the Upper Trapezius and Serratus Anterior force couple.

A
  • Allows rotation of the scapula
  • Maintains efficient length-tension relationship for the deltoid
  • Prevents impingement of the RTC from the coracoacromial arch
  • Stabilizes the scapula during movement

This stabilization allows for the recruitment and action of the scapula-humeral muscles.

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13
Q

What is the primary function of the Rotator Cuff (RTC) musculature?

A

To create stability at the glenohumeral joint throughout a range of motion

The RTC is crucial for maintaining the position of the humeral head.

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14
Q

What does the RTC musculature do to the humeral head during shoulder movement?

A

Depresses the humeral head away from the coracoacromial arch and compresses it into the glenoid fossa

This is important for seating the humeral head within the glenoid labrum.

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15
Q

Which muscles are part of the anterior and posterior Rotator Cuff?

A
  • Anterior RTC: Subscapularis
  • Posterior RTC: Infraspinatus, Teres Minor

These muscles are key in maintaining depression and compression of the humeral head.

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16
Q

True or False: The RTC muscles are primarily inactive during midranges of shoulder elevation.

A

False

The RTC muscles are primarily active throughout the midranges of shoulder elevation.

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17
Q

How does the RTC contribute to the alignment of the humeral head?

A

It balances the humeral head in central alignment due to its line of pull

This is essential for maintaining stability during shoulder movements.

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18
Q

What is scapular dyskinesis?

A

A change or abnormality in the normal resting position or dynamic movement of the scapula

Scapular dyskinesis may be a specific response to shoulder injury or a non-specific response to other conditions.

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19
Q

What are the three common patterns of scapular dyskinesis?

A
  1. Loss of upward rotation
  2. Excessive scapular internal rotation
  3. Excessive scapular anterior tilt

These patterns relate to the dynamic control of the scapula.

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20
Q

What could cause the upper trapezius to become weak?

A

Excessive scapular internal rotation could be a result of decreased activation of the Serratus Anterior

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21
Q

What could cause decreased activation of the serratus anterior?

A

Excessive scapular anterior tilt could be a result of a tight pectoralis minor on the same side

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22
Q

“SICK” Scapula is used to describe the presentation of scapular dyskinesis. What does “SICK” stand for?

A

Scapular Malalignment/Malposition
Inferior-medial border prominence
Coracoid malposition and pain
Kinesis Abnormalities

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23
Q

What is the function of the Suprascapular Nerve? What are its different branches?

A
  • This is a motor nerve to the Supraspinatus and Infraspinatus

Also does sensory to the Posterior GH joint capsule and Acromioclavicular joint

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24
Q

How can the Suprascapular Nerve become entrapped?

A

It can become entrapped as it runs through the spinal notch of the superior aspect of the scapula.
- Any space occupying lesion, cyst or tumor may cause compression of the nerve

25
Q

Clinically, Will you see the suprascapular nerve compressed or tensioned?

A

Clinically we will see that the nerve has become tensioned, if there is excessive protraction or repetitive protraction, the nerve can become tensioned and may cause significant pain in the posterior aspect of GH joint

26
Q

With the suprascapular nerve, what would happen if there is tension for long time?

A

We will see motor loss of the supraspinatus and infraspinatus and pain in the posterior aspect of the GH joint

27
Q

In terms of treatment, how do you treat a nerve that is under too much tension or there is repetitive protraction?

A

We must keep the scapular in a retracted position, can be used with taping, bracing or postural cue.
- This will put the nerve in more slack

28
Q

What is the function of the Dorsal Scapular Nerve?

A

A motor nerve to the Rhomboid and Levator Scapulae

29
Q

How can the Dorsal Scapular Nerve get entrapped?

A

This nerve tends to get entrapped between the scalenes, due to muscle tightness associated with poor posture or just tightness in general.
- Also 1st rib hypomobility may cause muscle tightness leading to entrapment

30
Q

Those patient that have a Dorsal Scapular Nerve Entrapment, they will typically present with what?

A

Patients will come with a diagnosis of another shoulder dysfunction; impingement syndrome, tendinopathy, bursitis

31
Q

What is common to find objectively with those patients with a Dorsal Scapular Entrapment?

A

They would have weak levator scapulae, rhomboids and tight scalenes

32
Q

What percentage of all fractures do clavicle fractures account for?

A

5-10%

Clavicle fractures account for 35-40% of shoulder girdle injuries in adults.

33
Q

What is the most commonly fractured bone in childhood?

A

Clavicle

34
Q

What common MOI for clavicle fractures?

A

FOOSH (fall on an outstretched hand)

Other causes include a fall or blow to the shoulder and direct blows (although less common).

35
Q

What are the classic presentations following a clavicular fracture?

A

Guarded shoulder motions and difficulty elevating the arm beyond 60 degrees

A clavicular deformity may also be observable.

36
Q

What type of tenderness is associated with clavicular fractures?

A

Exquisite tenderness to palpation or percussion (boney tap) over the fracture site

37
Q

What is the typical duration of immobilization for a clavicle fracture?

A

3-6 weeks

This is with a sling and figure-of-eight strap

38
Q

What radiographic finding confirms a clavicular fracture diagnosis?

A

Radiograph

39
Q

What type of exercises can be initiated once a clinical union of the clavicle has been established?

A

AAROM and AROM exercises for the shoulder

40
Q

When should joint mobilizations begin after clavicle fracture immobilization?

A

Immediately after the period of immobilization

41
Q

What muscles are targeted for strengthening exercises after a clavicular fracture?

A
  • Deltoid
  • Pectoralis major
  • Upper trapezius

These are prescribed when appropriate

42
Q

What is the normal healing time for clavicular fractures in young children?

A

6 weeks

43
Q

What is the normal healing time for clavicular fractures in adults?

A

8 weeks

44
Q

Under what circumstances is surgical intervention indicated for clavicular fractures?

A
  • Neurovascular compression
  • Open fracture
  • Associated fractures
  • Marked displacement
45
Q

What is the most common type of humeral fracture in young and elderly patients?

A

Proximal humeral fracture

This fracture occurs in the proximal third of the humerus.

46
Q

How does a proximal humeral fracture commonly present in skeletally immature patients?

A

As an epiphyseal fracture of the proximal humeral growth plate

This is often due to a direct blow or a FOOSH (fall on outstretched hand) injury.

47
Q

What typically causes proximal humeral fractures in elderly patients?

A

Minimal trauma through osteopenic bone

Osteopenia makes bones more susceptible to fractures with less force.

48
Q

What is the usual treatment approach for stable proximal humeral fractures?

A

Conservative treatment emphasizing control of distal edema and stiffness

Early motion at the shoulder is also important to prevent arthrofibrosis.

49
Q

How long is the arm typically immobilized in a sling for a nondisplaced stable fracture?

A

Approximately 2 weeks

This is until pain and discomfort subside.

50
Q

For a nondisplaced but unstable proximal humeral fracture, what is the typical immobilization period?

A

Approximately 4 weeks

This classification indicates a higher risk of displacement.

51
Q

When are AROM exercises for the wrist and hand initiated after immobilization?

A

Immediately after immobilization

This helps maintain mobility and prevent stiffness.

52
Q

When can passive and active-assisted exercises for the shoulder typically be initiated after injury?

A

Approximately 1 week after injury

This timing helps in early rehabilitation.

53
Q

What signifies clinical unity in the healing of a proximal humeral fracture?

A

Fracture fragments move in unison and movement is free of crepitation

This indicates a stable healing process.

54
Q

When are gentle AROM exercises for the shoulder and elbow initiated post-injury?

A

When clinical unity is established

This is crucial for recovery and rehabilitation.

55
Q

When are progressive resistive exercises typically initiated following a proximal humeral fracture?

A

At 6-8 weeks post-injury

This phase focuses on strengthening the shoulder and elbow.

56
Q

What are the common mechanisms of injury for scapular fractures?

A

Injuries typically result from:

  • Direct blow with significant force (e.g., motor vehicle accident, fall)
  • Direct downward force to the shoulder (acromion injuries)
  • Anterior or posterior force applied to the shoulder (scapular neck fractures)
  • Force transmitted along the humerus after a fall onto a flexed elbow (glenoid rim fractures)
  • Direct blow to the lateral shoulder (stellate glenoid fractures)
  • Direct blow to the superior aspect of the shoulder or forceful muscular contraction (coracoid process fractures)

This classification helps in understanding the type of force that leads to specific fracture types.

57
Q

What are the common findings associated with scapular fractures?

A

Common findings include:

  • Tenderness
  • Edema
  • Ecchymosis over the affected area
  • Upper extremity held in adduction
  • Increased pain with attempts to abduct the extremity

These findings indicate the severity and location of the fracture.

58
Q

How are most scapular fractures treated?

A

Most scapular fractures can be treated without surgery through:

  • 7-10 days of sling immobilization
  • Progressing regimen of pendular and gentle PROM exercises
  • Transition to AAROM and AROM exercises as healing allows
  • Strengthening exercises for muscles attached to the scapula at the earliest opportunity

This is the Progression!!!!

The treatment plan emphasizes conservative management to promote healing.

59
Q

What is Compartment Syndrome?

A

This is a condition in which myoneural anoxia results from a prolonged increase in tissue pressure within a closed osseofascial space, compromising the local blood flow of skeletal muscles and resulting ischemia and ultimately necrosis

PTMMD (33 decks)

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