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Ortho UE > Shoulder lecture > Flashcards

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

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2
Q

what are the joints that make up the shoulder

A

1) GH
2) Scapulothorastic
3) AC
4) SC

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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

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4
Q

Joint Centration

A

achieved by the combined neuro motor tasks of stabilization and dissociation to position the joint properly in space.

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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

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6
Q

Global muscles definition

A

involved in the movement of the joint by transferring and absorbing forces from the extremities

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7
Q

what is the closed pack position of the GH

A

90 degrees abd, and full ER

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8
Q

what is the open pack position of the GH

A

55 degrees ABD and 30 degrees horizontal ADD.

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9
Q

what is the capsular pattern of the shoulder

A

ER, Abd, and IR

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10
Q

What should you test for if the patient reports instability of the shoulder

A

Labrum tests: apprehension, relocation, jerks, sulcus

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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.

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12
Q

what should you test for if the pt reports of painful overhead arc

A

check for the SAPS and RCRPS clusters

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13
Q

what should you test for if the patient reports of nighttime awakening

A

internal derangement

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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

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15
Q

what muscles would be tight in kiber type 1

A

pec minor and short head of the biceps

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16
Q

what muscles would be weak in kiber. type 2

A

LT, lats, and serratus

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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

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18
Q

what muscles are weak in kiber type 2

A

serratus and lower traps

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19
Q

kiber type 3

A

superior border of the scapula is elevated in response to movement. Common in frozen shoulder and RCRPS

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20
Q

what muscles tight in kiber type 3

A

upper trap

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21
Q

what muscles are weak in kiber type 3

A

lower trap

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22
Q

what vertebral level is the superior lateral point of the spine of the scapula

A

C7

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23
Q

what vertebral level is the inferior medial point of the spine of the scapula

A

T3

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24
Q

what vertebral level is the inferior angle of the scapula

A

T7

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25
Q

what vertebral level is the pelvis

A

L3-L4

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26
Q

What is the mechanism of AC joint separation

A

Traumatic
- fall on outstretched arms
- direct blow or landing on the anterior shoulder

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27
Q

what would the subjective be of an AC joint separation

A
  • pain relief with cradling the arm
  • localized pain over the AC joint
  • pain with flexion, abduction, and horizontal ADD
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28
Q

what would the objective be of an AC joint separation

A
  • 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
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29
Q

Type 1 AC joint seperation

A

AC joint ligaments are partially or completely disrupted but coracoclavicular ligaments are in tact

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30
Q

Type 2 AC joint seperation

A

AC joint ligaments are torn in addition to the coracoclavicular ligaments are partially disrupted

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31
Q

Type 3 AC joint seperation

A

the coracoclavicular ligaments are completely disrupted and there is complete separation of the clavicle from the acromion

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32
Q

Type 4-6 AC joint seperation

A

very uncommon. the periosteum of the clavical and/or the deltoid and trapezius muscle are also torn, causing wide spread displacement

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33
Q

what is the treatment goal of a AC joint seperation

A

reduce direct pressure and traction at the AC joint

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34
Q

prognosis/ RTS for type 1 and 2 AC joint seperations

A

2-4 weeks

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35
Q

what is the tx for type 1 and 2 AC joint seperation

A

RICE, gental ROM, and stretch traps and deltoids

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36
Q

what is the tx for type 3 and 4 AC joint seperation

A

refer out for surgery

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37
Q

Phase 1 AC joint seperation post op ROM limitations for first 6 weeks

A
  • flexion limited to 90
  • limited IR and ER
  • no horizontal ADD
  • no lifting objects over 5 lbs
  • no stretching
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38
Q

Phase 1 AC joint seperation post op treatment ideas

A
  • pendulums
  • supine shoulder flex to 90
  • supine ER to neutral
  • Scapular retraction
  • ISO metric holds in all planes
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39
Q

phase 2 AC joint seperation post op treatment (7-12 weeks) goals

A

restore normal ROM in all planes, increase strength and neuromuscular control, increase proprioception

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40
Q

phase 3 AC joint seperation post op treatment (13-18 weeks) goals

A

horizontal ADD stretching, IR behind the back stretching, full ER to 90 stretching

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41
Q

when can push ups at the wall be implemented into post op AC rehab?

A

12 weeks post surgery

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42
Q

when can weight training be implemented into post op AC rehab

A

16 weeks post surgery

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43
Q

when can UE plyometrics and RTS throwing be implemented into post op AC rehab

A

19 weeks post surgery

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44
Q

what is primary adhesive capsulitis

A

idiopathic, progressive, and painful loss of AROM and PROM (diabetes is included in this one)

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45
Q

what is secondary adhesive capsulitis

A

traumatic in origin or related to a disease processes. The patient is able to pinpoint a time of onset.

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46
Q

how long does the “pre freezing” stage 1 adhesive capsulitis last

A

1 to 3 mo

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47
Q

characteristics of the pre freezing stage 1 adhesive capsulitis

A
  • shoulder aches when not using
  • sharp/stabbing pain when shoulder is moved
  • loss of ER
  • pain is the hallmark feature of this phase
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48
Q

how long does the freezing phase 2 of adhesive capsulitis last

A

3 to 9 mo

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49
Q

what are the characteristics of the freezing phase 2 of adhesive capsulitis

A
  • progressive loss of ROM and pain at night.
  • limited by stiffness and pain
  • hallmark feature is stiffness
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50
Q

how does does the thawing phase 3 of adhesive capsulitis last

A

9 to 14 months

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51
Q

what are the characteristics of the thawing phase 3 of adhesive capsulitis

A

pain will start to decrease and patient will start to restore ROM

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52
Q

reminder to self: ask Dr. B about the 2 different charts for the phases of adhesive capsulitis in the lecture (3 or 4 phases)

A
53
Q

what is the subjective of adhesive capsulitis

A
  • diffuse aching
  • difficulty sleeping on involved shoulder
  • difficulty with dressing and grooming
54
Q

what are the 3 characteristics of adhesive capsulitis

A

1) insidious onset of severe pain and stiffness
2) decreased ER ROM
3) negative radiographic findings

55
Q

what are the objective findings of adhesive capsulitis

A
  • 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
Q

how long does adhesive capsulitis typically last

A

18 mo to 3 years

57
Q

what is the primary goal of PT for adhesive capsulitis

A

restore ROM through the application of controlled tensile stresses to produce stretching of the restricted tissue

58
Q

what to do with low irritability adhesive capsulitis patients

A

aggressive soft tissue and joint mobilization

59
Q

what to do with high irritability adhesive capsulitis patients

A

pain easing manual therapy techniques

60
Q

what treatments have a grade A for adhesive capsulitis

A

1) shock wave therapy
2) stretching
3) steroid injections
4) laser therapy

61
Q

what treatment has a grade C for adhesive capsulitis

A

manual muscle release techniques

62
Q

what are the mechanisms of injury of a SLAP tear

A

fall on outstretched arms, traction from throwing deceleration, peel back from being in abduction and max ER from throwing acceleration)

63
Q

what is the subjective of biceps tendonitis

A
  • pinpoint tenderness over the bicipital groove
  • possible loss of shoulder ROM similar to RTCPS
  • positive special tests
64
Q

what are the special tests for biceps tendonitis

A

1) active compression
2) passive distraction
3) biceps load 1 and 2
4) anterior slide
5) crank test
6) yergason
7) speeds

65
Q

what muscles should NOT be strengthened in biceps tendonopathy

A
  • pec major
  • upper traps
66
Q

what joints should NOT be thrust manipulated in biceps tendonopathy

A
  • C/S
  • GH
67
Q

what soft tissue techniques should NOT be done on biceps tendonopathy

A
  • deep transverse friction
  • instrument assisted soft tissue mobilization
68
Q

should biophysical agents (modalities) be used on biceps tendonopathy patients

A

NO (maybe cryotherapy or moist heat and dry needling of the biceps muscle belly)

69
Q

what other techniques SHOULD be used for biceps brachii tendonopathy

A

NSAIDS and cognitive behavioral therapy

70
Q

what is the most common direction of GH dislocation/ subluxation

A

anterior and inferior

71
Q

what type of people are more prone to GH joint instability

A

young women, post large RTC tears, and athletes younger then 40

72
Q

what are the two types of Gh joint instability

A

1) TUBS
2) AMBRI

73
Q

what does TUBS stand for

A

Traumatic event, unidirectional, associated with a bankart lesion that usually requires surgery

74
Q

what does AMBRI stand for

A

Atraumatic, multidirectional, maybe bilateral, best treated by rehabilitation, inferior capsular shift is the surgery performed if rehab fails

75
Q

what is the subjective for GH instability

A
  • 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
Q

what is the objective for GH instability

A
  • positive special tests
  • apprehension with transverse plane ROM
  • generalized ligament laxity
77
Q

what are the special tests for GH instability

A

apprehension test, relocation test, jerk test, sulcus sign, and posterior instability

78
Q

what is the prognosis of GH instability

A

risk of recurrent instability is greater in younger patients and repeated subluxers

79
Q

what is GH joint OA

A

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
Q

what is the subjective for GH OA

A
  • 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
Q

what is the objective for GH OA

A
  • 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
Q

PT tx for shoulder OA

A
  • do closed chain exercises first
  • total shoulder indicated when overall function is impaired and ADLS are significantly limited
83
Q

what is the subjective of SAPS

A
  • 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
Q

subacrominal pain syndrome (SAPS) definition

A

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
Q

what is stage 1 SAPS objective

A

tenderness of the supra insertion and anterior acromin, painful arc, and weakness of the RTC secondary to pain

84
Q

what is stage 2 SAPS objective

A

crepitus or catching at 100 degrees and restriction of PROM due to fibrosis

85
Q

what is stage 3 SAPS objective

A

atrophy of the infra and supra and limitation of active ROM

86
Q

what are the special tests for SAPS

A

1) hawkins kennedy
2) neers
3) painful arc
4) full can empty can
5) Resisted ER at 90

87
Q

definition of rotator cuff related pain syndrome (RCRPS)

A

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
Q

subjective for rotator cuff related pain syndrome (RCRPS)

A
  • 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
Q

what would the measurement of a small rotator cuff tear be

A

less then 1 cm

90
Q

what would the measurement of a medium rotator cuff tear be

A

1-3cm

91
Q

what would the measurement of a large rotator cuff tear be

A

3-5 cm

92
Q

what would the measurement of a massive rotator cuff tear be

A

5+ cm

93
Q

what are the objective findings in rotator cuff related pain syndrome

A
  • 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
Q

what are the retear rates of rotator cuff repair

A

25-70% most that fail fail within the first 3-6 months post surgery

94
Q

what is the criteria for rotator cuff repair post op intervention

A
  • 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
Q

for how long post rotator cuff repair should you function under 15% muscular EMG activity

A

6-8 weeks

96
Q

exercises for less then 15% EMG activation of the Supra

A

AAROM in all directions however avoiding AAROM were you have to use the surgical side effort

97
Q

exercises for less then 15% EMG activation of the infra

A

AAROM in all directions avoid active contraction into ER

97
Q

exercises for less then 15% EMG activation of the teres

A
  • standing ER at 0 degrees with towel
  • standing ER in the scapular plane
98
Q

exercises for less then 15 % EMG activation of the subscap

A
  • pulley-assisted elevation
  • table slide
  • prone shoulder flexion
  • seated row
  • wall-assisted external rotation
99
Q

what is the time line for being able to do active assisted to AROM work in all planes post RTC surgery

A

7-9 weeks

100
Q

what is the time line to progress to push and pull strengthening post RTC surgery

A

10-12 weeks

101
Q

what is the time line for push up and return to sport actives (over 50% EMG activity) post RTC surgery

A

20 weeks

102
Q

what is the the benefit of the strict 2 week immobilization for post op RTC

A

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
Q

what is a slap lesion

A
  • injury to the superior glenoid labrum and the biceps
  • can be from an injury or due to overuse
104
Q

what are the mechanisms of a SLAP lesion

A
  • FOOSH
  • sudden deceleration, traction or loading of the biceps
  • chronic anterior and posterior instability
105
Q

Type 1 slap lesion

A

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
Q

Type 2 slap lesion

A

pathological detachment of the labrum and the biceps tendon anchor resulting in a loss of the stabilizing of the anterior shoulder

107
Q

Type 3 slap lesion

A

vertical tear of the labrum, similar to the bucket handle, remaining portions of the labrum and the biceps tendon are still in tact.

108
Q

Type 4 slap lesion

A

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
Q

Type 5 slap lesion

A

presence of a bankart lesion of the anterior capsule that extends into the superior labrum

110
Q

Type 6 slap lesion

A

disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear

111
Q

Type 7 slap lesion

A

extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament

112
Q

what is the obejective of a SLAP lesion

A
  • pain or clicking in positions that place stress on the biceps
  • similar symptoms to instability and RCPRS
  • positive SLAP special test
113
Q

what is the subjective of a SLAP lesion

A
  • hx of trauma or overuse
  • complaints of pain or instability with OH activities and symptoms of clicking, catching, or locking
114
Q

what are the special tests for a SLAP lesion

A
  • o’brians
  • compression and rotation
  • crank test
  • biceps load 2
  • kim test
  • jerk test
115
Q

what is the intervention for SLAP lesions

A

address hyper mobility and instability of the shoulder

116
Q

post op SLAP when can you initiate isometrics/ ER IR

A

4-6 weeks

117
Q

post op SLAP when can you initate weight training and return to sport

A

weeks 12-24

118
Q

what is the description of thoracic outlet syndrome (TOS)

A

symptoms due to compression of the brachial plexus or vasculature in the thorastic outlet. more common in women ages 20-50 years old

119
Q

what is the subjective of thoracic outlet syndrome

A
  • 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
Q

what are the objective of thoracic outlet syndrome

A
  • 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
Q

what is the treatment for TOS

A

postural correction. 50-90% of patients respond well to conservative tx

122
Q

what are the special tests for TOS

A
  • adson
  • allen pec minor test
  • costoclavicular test
  • roos
  • hyperabduction maneuver
  • passive shoulder shrug

need 3+ to be positive

123
Q

what is the criteria for surgical intervention for TOS

A
  • failure to respond to conservative treatment for 4 months
  • signs of muscular atrophy
  • intermittent paresthesias being replaced by sensory loss
  • pain becoming incapacitating
124
Q

what are scapular upward rotators

A
  • upper trap
  • serratus anterior
  • lower trap
125
Q

what are the scapular downward rotators

A
  • rhomboids
  • levator
  • pec minor

Ortho UE (4 decks)

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