Shoulder lecture Flashcards
1
Q
what are the bones that make up the shoulder
A
1) scapula
2) clavicle
3) humeral head
4) posterior rib cage
2
Q
what are the joints that make up the shoulder
A
1) GH
2) Scapulothorastic
3) AC
4) SC
3
Q
Approximation
A
the compression of a segment/joint surface that is sues to promote stability in the joint by stimulating type 1 receptors that facilitate postural stability
4
Q
Joint Centration
A
achieved by the combined neuro motor tasks of stabilization and dissociation to position the joint properly in space.
5
Q
Local muscles definition
A
involved in joint position or stabilization. These muscles provide the stability to allow for the mobility of the joint
6
Q
Global muscles definition
A
involved in the movement of the joint by transferring and absorbing forces from the extremities
7
Q
what is the closed pack position of the GH
A
90 degrees abd, and full ER
8
Q
what is the open pack position of the GH
A
55 degrees ABD and 30 degrees horizontal ADD.
9
Q
what is the capsular pattern of the shoulder
A
ER, Abd, and IR
10
Q
What should you test for if the patient reports instability of the shoulder
A
Labrum tests: apprehension, relocation, jerks, sulcus
11
Q
what should you test for if the pt reports of loss of ROM into abduction or flexion
A
Check for SAPS: hawkins kennedy, neer, painful arc, empty can, full can, and shoulder iso ER.
12
Q
what should you test for if the pt reports of painful overhead arc
A
check for the SAPS and RCRPS clusters
13
Q
what should you test for if the patient reports of nighttime awakening
A
internal derangement
14
Q
what is kiber type 1
A
the anterior tilt of the scapula with a more prominent inferior angle when the patients hands are on their hips. there would be tenderness to palpation fo the coracoid process
15
Q
what muscles would be tight in kiber type 1
A
pec minor and short head of the biceps
16
Q
what muscles would be weak in kiber. type 2
A
LT, lats, and serratus
17
Q
kiber type 2
A
entire medial border of the scapula is off the ribs and the glenoid fossa moves anteriorly which increases the likelihood of anterior GH instability
18
Q
what muscles are weak in kiber type 2
A
serratus and lower traps
19
Q
kiber type 3
A
superior border of the scapula is elevated in response to movement. Common in frozen shoulder and RCRPS
20
Q
what muscles tight in kiber type 3
A
upper trap
21
Q
what muscles are weak in kiber type 3
A
lower trap
22
Q
what vertebral level is the superior lateral point of the spine of the scapula
A
C7
23
Q
what vertebral level is the inferior medial point of the spine of the scapula
A
T3
24
Q
what vertebral level is the inferior angle of the scapula
A
T7
25
what vertebral level is the pelvis
L3-L4
26
What is the mechanism of AC joint separation
Traumatic
- fall on outstretched arms
- direct blow or landing on the anterior shoulder
27
what would the subjective be of an AC joint separation
- pain relief with cradling the arm
- localized pain over the AC joint
- pain with flexion, abduction, and horizontal ADD
28
what would the objective be of an AC joint separation
- type 3 would have an obvious deformity
- swelling over the AC joint
- pain aggravated with H. ADD
- positive cross over/ jerks, AC resisted extension
- positive AC joint cluster
29
Type 1 AC joint seperation
AC joint ligaments are partially or completely disrupted but coracoclavicular ligaments are in tact
30
Type 2 AC joint seperation
AC joint ligaments are torn in addition to the coracoclavicular ligaments are partially disrupted
31
Type 3 AC joint seperation
the coracoclavicular ligaments are completely disrupted and there is complete separation of the clavicle from the acromion
32
Type 4-6 AC joint seperation
very uncommon. the periosteum of the clavical and/or the deltoid and trapezius muscle are also torn, causing wide spread displacement
33
what is the treatment goal of a AC joint seperation
reduce direct pressure and traction at the AC joint
34
prognosis/ RTS for type 1 and 2 AC joint seperations
2-4 weeks
35
what is the tx for type 1 and 2 AC joint seperation
RICE, gental ROM, and stretch traps and deltoids
36
what is the tx for type 3 and 4 AC joint seperation
refer out for surgery
37
Phase 1 AC joint seperation post op ROM limitations for first 6 weeks
- flexion limited to 90
- limited IR and ER
- no horizontal ADD
- no lifting objects over 5 lbs
- no stretching
38
Phase 1 AC joint seperation post op treatment ideas
- pendulums
- supine shoulder flex to 90
- supine ER to neutral
- Scapular retraction
- ISO metric holds in all planes
39
phase 2 AC joint seperation post op treatment (7-12 weeks) goals
restore normal ROM in all planes, increase strength and neuromuscular control, increase proprioception
40
phase 3 AC joint seperation post op treatment (13-18 weeks) goals
horizontal ADD stretching, IR behind the back stretching, full ER to 90 stretching
41
when can push ups at the wall be implemented into post op AC rehab?
12 weeks post surgery
42
when can weight training be implemented into post op AC rehab
16 weeks post surgery
43
when can UE plyometrics and RTS throwing be implemented into post op AC rehab
19 weeks post surgery
44
what is primary adhesive capsulitis
idiopathic, progressive, and painful loss of AROM and PROM (diabetes is included in this one)
45
what is secondary adhesive capsulitis
traumatic in origin or related to a disease processes. The patient is able to pinpoint a time of onset.
46
how long does the "pre freezing" stage 1 adhesive capsulitis last
1 to 3 mo
47
characteristics of the pre freezing stage 1 adhesive capsulitis
- shoulder aches when not using
- sharp/stabbing pain when shoulder is moved
- loss of ER
- pain is the hallmark feature of this phase
48
how long does the freezing phase 2 of adhesive capsulitis last
3 to 9 mo
49
what are the characteristics of the freezing phase 2 of adhesive capsulitis
- progressive loss of ROM and pain at night.
- limited by stiffness and pain
- hallmark feature is stiffness
50
how does does the thawing phase 3 of adhesive capsulitis last
9 to 14 months
51
what are the characteristics of the thawing phase 3 of adhesive capsulitis
pain will start to decrease and patient will start to restore ROM
52
reminder to self: ask Dr. B about the 2 different charts for the phases of adhesive capsulitis in the lecture (3 or 4 phases)
53
what is the subjective of adhesive capsulitis
- diffuse aching
- difficulty sleeping on involved shoulder
- difficulty with dressing and grooming
54
what are the 3 characteristics of adhesive capsulitis
1) insidious onset of severe pain and stiffness
2) decreased ER ROM
3) negative radiographic findings
55
what are the objective findings of adhesive capsulitis
- varies according to the phase
- inability to raise the involved shoulder correctly
- point tenderness over the bicipital groove
- restriction of the anterior and inferior glide of the GH
- pain at end range
56
how long does adhesive capsulitis typically last
18 mo to 3 years
57
what is the primary goal of PT for adhesive capsulitis
restore ROM through the application of controlled tensile stresses to produce stretching of the restricted tissue
58
what to do with low irritability adhesive capsulitis patients
aggressive soft tissue and joint mobilization
59
what to do with high irritability adhesive capsulitis patients
pain easing manual therapy techniques
60
what treatments have a grade A for adhesive capsulitis
1) shock wave therapy
2) stretching
3) steroid injections
4) laser therapy
61
what treatment has a grade C for adhesive capsulitis
manual muscle release techniques
62
what are the mechanisms of injury of a SLAP tear
fall on outstretched arms, traction from throwing deceleration, peel back from being in abduction and max ER from throwing acceleration)
63
what is the subjective of biceps tendonitis
- pinpoint tenderness over the bicipital groove
- possible loss of shoulder ROM similar to RTCPS
- positive special tests
64
what are the special tests for biceps tendonitis
1) active compression
2) passive distraction
3) biceps load 1 and 2
4) anterior slide
5) crank test
6) yergason
7) speeds
65
what muscles should NOT be strengthened in biceps tendonopathy
- pec major
- upper traps
66
what joints should NOT be thrust manipulated in biceps tendonopathy
- C/S
- GH
67
what soft tissue techniques should NOT be done on biceps tendonopathy
- deep transverse friction
- instrument assisted soft tissue mobilization
68
should biophysical agents (modalities) be used on biceps tendonopathy patients
NO (maybe cryotherapy or moist heat and dry needling of the biceps muscle belly)
69
what other techniques SHOULD be used for biceps brachii tendonopathy
NSAIDS and cognitive behavioral therapy
70
what is the most common direction of GH dislocation/ subluxation
anterior and inferior
71
what type of people are more prone to GH joint instability
young women, post large RTC tears, and athletes younger then 40
72
what are the two types of Gh joint instability
1) TUBS
2) AMBRI
73
what does TUBS stand for
Traumatic event, unidirectional, associated with a bankart lesion that usually requires surgery
74
what does AMBRI stand for
Atraumatic, multidirectional, maybe bilateral, best treated by rehabilitation, inferior capsular shift is the surgery performed if rehab fails
75
what is the subjective for GH instability
- looseness of the shoulder
- noisy shoulder
- maybe hx of trauma
- sensation of slipping out of joint abd and ER
- AMBRI pt have a vague symptoms but they are all related
76
what is the objective for GH instability
- positive special tests
- apprehension with transverse plane ROM
- generalized ligament laxity
77
what are the special tests for GH instability
apprehension test, relocation test, jerk test, sulcus sign, and posterior instability
78
what is the prognosis of GH instability
risk of recurrent instability is greater in younger patients and repeated subluxers
79
what is GH joint OA
the progressive destruction of the joint cartilage with loss of joint space which can be a long term consequence of trauma (dislocations, fx, and large RTC tears)
80
what is the subjective for GH OA
- gradual onset of deep shoulder pain and stiffness
- pain is worse posteriorly
- progressive loss of ROM and function
- HX of trauma to the shoulder
81
what is the objective for GH OA
- forward humeral head, protracted scapula
- tenderness under the coracoid process
- swelling around the joint and in the infraclavicular fossa
- decreased active and passive ROM in all planes
- crepitation with circumduction
82
PT tx for shoulder OA
- do closed chain exercises first
- total shoulder indicated when overall function is impaired and ADLS are significantly limited
83
what is the subjective of SAPS
- pain felt down the lateral aspect of the arm with pain near the insertion of the deltoid, over the anterior proximal humerus or in the periacromial area
- functional loss of shoulder motion due to pain, stiffness, and weakness with a catching sensation in flexion and IR
- difficulty sleeping on the involved side
- pain with ADLs
83
subacrominal pain syndrome (SAPS) definition
decreased volume of the coracoacromial arch which can lead to impingement of the supra, long head of the biceps, subacromial bursa, coracohumeral ligament suprascapular nerve or suprascapular artery
84
what is stage 1 SAPS objective
tenderness of the supra insertion and anterior acromin, painful arc, and weakness of the RTC secondary to pain
84
what is stage 2 SAPS objective
crepitus or catching at 100 degrees and restriction of PROM due to fibrosis
85
what is stage 3 SAPS objective
atrophy of the infra and supra and limitation of active ROM
86
what are the special tests for SAPS
1) hawkins kennedy
2) neers
3) painful arc
4) full can empty can
5) Resisted ER at 90
87
definition of rotator cuff related pain syndrome (RCRPS)
a traumatic or degenerative injury described by its size, location, direction, and depth involving usually longitudinal tears in the critical zones (avascular zones). normally in people over the age of 40
88
subjective for rotator cuff related pain syndrome (RCRPS)
- weakness and pain with activities that involve ABD and ER
- localized pain over the upper back, deltoid, shoulder, and arm
- popping sensation may be present
89
what would the measurement of a small rotator cuff tear be
less then 1 cm
90
what would the measurement of a medium rotator cuff tear be
1-3cm
91
what would the measurement of a large rotator cuff tear be
3-5 cm
92
what would the measurement of a massive rotator cuff tear be
5+ cm
93
what are the objective findings in rotator cuff related pain syndrome
- muscle atrophy / asymmetry
- point tenderness at the greater tuberosity
- loss of PROM and AROM depending on extent of injury
- positive RCRPS special tests
- with small tears: weakness might not be detected and pt will have full ROM however positive painful arc
- massive tears: sudden profound weakness with inability to raise the arm overhead and a positive drop arm sign
94
what are the retear rates of rotator cuff repair
25-70% most that fail fail within the first 3-6 months post surgery
94
what is the criteria for rotator cuff repair post op intervention
- patient younger than 60 years old
- failure to improve after conservative treatment for at least 6 weeks
- presence of a full thickness tear
- pts need to use the involved shoulder for work
- ability and willingness of the patient
95
for how long post rotator cuff repair should you function under 15% muscular EMG activity
6-8 weeks
96
exercises for less then 15% EMG activation of the Supra
AAROM in all directions however avoiding AAROM were you have to use the surgical side effort
97
exercises for less then 15% EMG activation of the infra
AAROM in all directions avoid active contraction into ER
97
exercises for less then 15% EMG activation of the teres
- standing ER at 0 degrees with towel
- standing ER in the scapular plane
98
exercises for less then 15 % EMG activation of the subscap
- pulley-assisted elevation
- table slide
- prone shoulder flexion
- seated row
- wall-assisted external rotation
99
what is the time line for being able to do active assisted to AROM work in all planes post RTC surgery
7-9 weeks
100
what is the time line to progress to push and pull strengthening post RTC surgery
10-12 weeks
101
what is the time line for push up and return to sport actives (over 50% EMG activity) post RTC surgery
20 weeks
102
what is the the benefit of the strict 2 week immobilization for post op RTC
results in increased type 1 collegan fibers and less scar formation then early mobilization for post op RTC. allows for proper tendon-bone integration
103
what is a slap lesion
- injury to the superior glenoid labrum and the biceps
- can be from an injury or due to overuse
104
what are the mechanisms of a SLAP lesion
- FOOSH
- sudden deceleration, traction or loading of the biceps
- chronic anterior and posterior instability
105
Type 1 slap lesion
fraying and degeneration of the edge of the superior labrum. pt loses the ability to horizontally adduct or ER with the forearm in a pronated position without pain
106
Type 2 slap lesion
pathological detachment of the labrum and the biceps tendon anchor resulting in a loss of the stabilizing of the anterior shoulder
107
Type 3 slap lesion
vertical tear of the labrum, similar to the bucket handle, remaining portions of the labrum and the biceps tendon are still in tact.
108
Type 4 slap lesion
extension of the bucket handle tear into the biceps tendon with the portions of the labral flap and biceps tendon displaceable into the GH
109
Type 5 slap lesion
presence of a bankart lesion of the anterior capsule that extends into the superior labrum
110
Type 6 slap lesion
disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear
111
Type 7 slap lesion
extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament
112
what is the obejective of a SLAP lesion
- pain or clicking in positions that place stress on the biceps
- similar symptoms to instability and RCPRS
- positive SLAP special test
113
what is the subjective of a SLAP lesion
- hx of trauma or overuse
- complaints of pain or instability with OH activities and symptoms of clicking, catching, or locking
114
what are the special tests for a SLAP lesion
- o'brians
- compression and rotation
- crank test
- biceps load 2
- kim test
- jerk test
115
what is the intervention for SLAP lesions
address hyper mobility and instability of the shoulder
116
post op SLAP when can you initiate isometrics/ ER IR
4-6 weeks
117
post op SLAP when can you initate weight training and return to sport
weeks 12-24
118
what is the description of thoracic outlet syndrome (TOS)
symptoms due to compression of the brachial plexus or vasculature in the thorastic outlet. more common in women ages 20-50 years old
119
what is the subjective of thoracic outlet syndrome
- vague and variable symptoms of diffuse arm pain and shoulder pain when elevated to 90 degrees
- pain localized at the neck, face, head, UE, Chest, shoulder or axilla
- UE parethesias, numbess, weakness, heaviness, fatigability, swelling
- more common to have neural S/S then to have vasculature
120
what are the objective of thoracic outlet syndrome
- pallor of arm or swelling
- bruits on ascultation
- lack of distal pulses
- differences in peripheral nerve sensory and function
- postitive special tests
- C8-T1 most commonly compressed leading to lack of sensation in the 4th and 5th digits
121
what is the treatment for TOS
postural correction. 50-90% of patients respond well to conservative tx
122
what are the special tests for TOS
- adson
- allen pec minor test
- costoclavicular test
- roos
- hyperabduction maneuver
- passive shoulder shrug
need 3+ to be positive
123
what is the criteria for surgical intervention for TOS
- failure to respond to conservative treatment for 4 months
- signs of muscular atrophy
- intermittent paresthesias being replaced by sensory loss
- pain becoming incapacitating
124
what are scapular upward rotators
- upper trap
- serratus anterior
- lower trap
125
what are the scapular downward rotators
- rhomboids
- levator
- pec minor
