Shoulder McGee Flashcards
AMBRI
Atraumatic Multidirectional Bilateral Rehabilitation (as appropriate) and rarely Inferior capsular shift surgery - Not typically recommended for surgery & May be a primary instability factor for Secondary Impingement
TUBS
Traumatic Unilateral anterior with a Bankart lesion responding to Surgery
Empty can vs full can which is better for testing supraspinatus?
Full Can position tests supraspinatus strength better than Empty Can - Empty can position: strength tends to be limited by pain
Rotator Cuff avascular zone
Glenohumeral 0°: poor vascularity to RC tendons & 30-45° Abduction: vascularity to RC tendons optimized
Primary Anterior Stabilizers of Glenohumeral Joint
GH 0°: Subscapularis, GH 45°: Subscapularis & Middle Glenohumeral Ligament, GH >90°: Inferior Glenohumeral Ligament & Biceps Brachii
Primary mechanism of anterior Glenohumeral dislocation
Trauma; indirect blow with shoulder in abduction, extension, & ER
Primary mechanism of posterior Glenohumeral dislocation
Axial loading of arm with shoulder in adduction, flexion, & IR, trauma to front of the shoulder, FOOSH
Traumatic dislocations can be associated with what nerve injuries
Axillary
Humeral shaft fractures can be associated with what nerve injuries
radial
What RTC repair has a slower progression due to weaker fixation of repair
Arthroscopic
What RTC repair has a vertical split between anterior and middle deltoid, but allows early initiation of deltoid AROM
Mini-Open
What RTC repair has a Deltoid detachment/release from clavicle or acromion, and has no deltoid AROM for 6-8 weeks
Open
RTC describe small, medium, and large tears:
5cm (large)
Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a small tear
Sling 7-10 days; Full ROM 4-6 weeks, 2-3 wks for isotonic ex
Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a medium tear
Sling 2-3 weeks; Full ROM 8-10 weeks, 3-4 weeks for isotonic ex
Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a larger tear
Sling 2-3 weeks; Full ROM 10-14 weeks, 3-4 weeks for isotonic ex
Which has a lower reoccurrance rate for instability surgery open or arthoscopic?
Open: standard procedure (recurrence rate <5%) vs Arthroscopic: slower rehab (recurrence rate 8-17%)
What type of surgery is used for instability?
Bankart and capsular shift (which spends more time in a immobilizer)
What directions can shoulder instability exist?
Ant, post, and multidirectional
Describe a Type I SLAP injury:
Degenerative fraying of superior labrum, Biceps attachment intact, Biceps anchor intact
Describe a Type I SLAP surgery
Superior labrum is debrided
Describe a Type I SLAP rehab
Pendulum after 1 week NO ER > neutral/extension of arm behind body x 4 weeks No stressful biceps activity x 3 months
Describe a Type II SLAP injury:
Biceps anchor pulled away from glenoid
Describe a Type II SLAP surgery
Lesion repaired with tacks, staples, or suture anchors
Describe a Type II SLAP rehab
More conservative than type I - Sling x 3 weeks
Describe a Type III SLAP injury:
Bucket-handle tear of superior labrum, Biceps anchor intact
Describe a Type III SLAP surgery
Torn fragment is resected
Describe a Type III SLAP rehab
Same as Type 1
Describe a Type IV SLAP injury:
Similar to Type 3- Tear extends to biceps tendon & Torn biceps tendon and labrum displaced into joint
Describe a Type IV SLAP surgery
30% tendon torn Older patient: labrum debrided, tendon tenodesis Young patient: arthroscopic suture repair
Describe a Type IV SLAP rehab
More conservative - Sling x 3 weeks
AC seperation MOI
Trauma to superior shoulder
AC seperation physical exam
Step deformity at AC (possible) (+) AC shear test Tenderness to AC joint Pain with shoulder elevation and/or abduction (+) xray findings
AC seperation differential Dx
Chronic conditions can increase stress to RC Concomitant clavicle fracture RC tear
AC seperation Tx
varies on grade, typically grade I, II, and usually III do not require surgery - grades higher than III do require surgery
Acute Bursitis/Calcific Tendonitis Hx and demographic
Idiopathic; can result from Tendonosis or viral infection Women > men Middle age > older > younger
Acute Bursitis/Calcific Tendonitis presentation
Capsular pattern: ER > ABD > IR Joint play restrictions in all directions, especially inferiorly: Histological changes in area of redundant fold Chronic cases can lead to secondary impingement
Acute Bursitis/Calcific Tendonitis differential Dx
Impingement Subscapularis spasm/tightness
Acute Bursitis/Calcific Tendonitis Tx
Regain motion at GH joint Regain ST rhythm Strengthen Typically self-limiting within 6-12 months Aquatic therapy should be considered
Bicipital Tendonitis Hx
Overuse/overtraining Overhead sports with racquet/throwing Pain at anterior shoulder
Bicipital Tendonitis presentation
Tenderness along Long Head of Biceps tendon (proximal portion) (+) Speeds test Pain with resisted shoulder flexion (typical); elbow flexion (occasional) (+) Horizontal Adduction with overpressure for symptom reproduction
Bicipital Tendonitis differential Dx
Supraspinatus tendonitis Subscapularis tendonitis Impingement
Bicipital Tendonitis Tx
Anti-inflammatory & rest Overhead activity modification Posterior capsule stretching Eccentric-specific strength training RC & ST strengthening
Neer Stages of Impingement Stage 1
Age: < 25 Pathology: Edema Clinical Presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test, RROM Abd/ER strong + pain
Neer Stages of Impingement Stage 2
Age: 25-40 Pathology: Fibrosis, tendonitis/bursitis Clinical presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test RROM Abd/ER strong + pain, Capsular pattern
Neer Stages of Impingement Stage 3
Age: >40 Pathology: bone spurs, tendon disruption Clinical presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test RROM Abd/ER weak + pain, Capsular pattern, “Squaring” of acromion (atrophy of deltoid and RC)
Neer Stages of Impingement Stage 4
similar to stage 3
Describe Primary Impingement
Abnormal mechanical relationship between rotator cuff and coracoacromial arch - Typically a “narrowing” of that arch
Primary Impingement Hx
Typically > 40 years old c/o anterior shoulder and upper lateral arm pain unable to sleep on affected side
Primary Impingement physical exam
Decreased ROM and strength (secondary to pain) (+) Hawkins-Kennedy & Neer Impingement signs Typically concomitant AC arthrosis exacerbated by: 1. internal rotation 2. abduction >90°
Primary Impingement differential Dx
RC tears Calcific tendonitis AC joint arthrosis Glenohumeral instability SLAP lesions Bicepital tendonitis Early adhesive capsulitis Tumors
Primary Impingement Tx
Surgical subacromial decompression (acromioplasty)
Describe Secondary Impingement
Narrowing of the subacromial space due to glenohumeral or scapulothoracic instability. Attempts by RC to compensate for lack of ligamentous/capsular stabilization results in fatigue of RC and superior migration of humeral head
Secondary Impingement Hx
Younger populations Typically participate in overhead sports: combinations of school and community league sports does not allow for “off-season” in pre/adolescent populations reports of “arm going dead”
Secondary Impingement physical exam
Glenohumeral instability with (+) apprehension test +) Full can, Empty can tests Scapular dyskinesia, winging, or abnormal motion Tight posterior Glenohumeral capsule
Secondary Impingement Tx
Addressing underlying impairment should resolve the problem
Posterior (Internal) Impingement: population and Hx
Typically in overhead athletes (tennis players, swimmers, throwers) During ABD+ER (cocking phase) the supraspinatus and infraspinatus muscles get ‘pinched’ at superior/posterior glenoid Occurs on undersurface (instead of bursa side) of RC Typically associated with anterior instability
Describe Neer
Maximal passive flexion of arm (overhead) compresses greater tuberosity against anteroinferior acromion
Describe Hawkins-Kennedy
Flexion to 90°, max passive IR, compresses supraspinatus against anterior coracoacromial ligament
Describe Cross-over
Stabilize superoposterior shoulder and maximally horizontal adduct patient’s arm across their body
Describe Painful arc
ROM that is painful, Typically 60-120°
Describe Lift-off
Dorsum of hand placed against back pocket, Patient lifts hand away from back, Inability to perform is (+)
Describe Drop sign
Passively place arm in 90° elbow flexion and abduction & max ER. Release arm. Inability for patient to maintain position (+)
Describe IR Lag
Same position as lift off, only examiner lifts arm away and asks patient to maintain position. (+) inability to maintain
Describe ER Lag
Passively place arm in 20° scapular elevation and 90° elbow flexion. Maximally ER. (+) inability to maintain position
