Shoulder Pathophysiology Flashcards
why is the shoulder so prone to instability?
bc of the amount of mobility at the jt with mostly ligamentous/muscular restrictions and not a lot of bony stability
how much space should be in the subacromial (SA) space?
4-11 mm
what are the anatomic variants that can cause impingement at the shoulder?
type 1 (straight) acromion
type 2 (curved) acromion
type 3 (hooked) acromion
what is the most problematic acromion type?
type 3
what is the least problematic acromion type?
type 1
what things can contribute to shoulder impingement?
decreased SA space
anatomic variants
shoulder girdle kinematics
RC pathology
degenerative changes
overuse
the critical zone largely involves what two structures?
subacromial bursa
supraspinatus tendon
tendinitis in the shoulder primarily effects what 2 tendons?
supraspinatus tendon
long head of the biceps (LHB) tendon
how can RC weakness/fatigue contribute to tendinitis?
bc it causes the humeral head to rise higher and irritate the tendons
how can posterior capsule tightness contribute to tendinitis?
bc it causes the humeral head to rise superiorly and irritate the tendons
mobility impairments in what jts may cause tendinitis in the shoulder?
GH, SC, ST, AC
what things may contribute to tendinitis?
RC weakness/fatigue
capsular restrictions
anatomic variations
mobility impairments
those with tendinitis may develop what?
calcific tendinopathy or rupture
what % of those with tendinitis develop calcific tendinitis?
3-7%
are males or females more likely to develop calcific tendinitis?
females
what age group is more likely to develop calcific tendinitis?
those over 40 y/o
how can we differentiate tendinitis?
resistance testing and palpation
how is bursitis different from tendinitis, fx, arthritis, or dislocation?
there is pain with movt, no pain with resistance (or very minimal pain), and (+) impingement signs
bursitis causes pain with passive motion in what directions?
abduction
IR
horizontal adduction
where would someone with shoulder bursitis be tender?
subacromially at the greater tuberosity with the arm in extension
what are the special tests for impingement?
Hawkins Kennedy
Neer
how do we perform the HK test?
in sitting, flex, IR, add the arm and push up on their elbow
what is a positive HK test?
pain in the shoulder
how do we perform the Neer test?
in sitting, flex, IR the arm over the head and stabilize the scap
what is a positive Neer test?
pain in the shoulder with passive overpressure
what are the s/s of stage 1 bursitis?
localized edema
TTT anterior acromion
painful arc
pain related RC weakness
what age group is mostly affected by stage 1 bursitis?
those under 25 y/o
what can cause stage 1 bursitis?
acute or repeated trauma
what are the interventions for stage 1 bursitis?
RICE
non-provocative RC training
OMPT (ortho manual PT)
what are the interventions for impingement?
control inflammation
modalities for pain and edema
TFM
RC training
OMPT for jt mobility
NM re-ed (ST)
AD modifications
surgery
t/f: US is the first choice modality to treat impingement pain and edema
false
RC training starts with ______ motions—-> _______ motions—> ______ motions
pure, multiplanar, provocative
what surgeries may be done for impingement?
acromioplasty
RC repair
SA decompression
what makes up 50-75% of all shoulder injuries?
RC pathology
the RC helps with what?
centration of the humeral head in the glenoid
t/f: the RC has a role in both mobility and stability
true
what muscles are most involved in RC pathology?
supraspinatus>infraspinatus> subscapularis
t/f: decreased SA can cause RC pathology
true
RC pathology causes tension in what motions?
horizontal adduction
IR
t/f: RC pathology can cause anterior translation
true
t/f: tears in the RC decrease as we age
false, tears increase with age
what % of cadavers over 40 y/o had full thickness RCT?
5-20%
what % of cadavers over 40 y/o had partial thickness RCT?
30-40%
what are the s/s of RC pathology?
painful arc
pain during/after activity
TTT over GT, coracoacromial lig, and LHB tendon
what are the special tests for RC pathology?
drop arm test
ER lag (dropping) sign
Hornblower’s sign
lift off test (and belly press)
full/empty can test
what muscle is the drop arm test for?
supraspinatus/infraspinatus
what muscle is the ER Lag (dropping) sign for?
infraspinatus
what muscle is the Hornblower’s sign for?
teres minor
what muscle is the lift off test (and belly press test) for?
subscapularis
what muscle is the full/empty can test for?
supraspinatus
what are the RC precautions for 6 weeks?
keep the arm below shoulder level
no horizontal adduction past neutral
no extension past neutral
no IR/ER in 90 deg abduction
no WB
no AROM
no PREs
t/f: pts with RC pathology are usually in a sling the first time we see them
true
what are the goals of phase 1 RCT repair?
pt ed
controlling pain
ROM
what are the interventions of phase 1 RCT repair 1 day post op?
pendulums
sling
distal AROM
what are the interventions of phase 1 RCT repair 7-10 days post op?
PROM flex/ER
modalities
t/f: no PREs or AROM are done in phase 1 RCT repairs
true
when is phase 1 RCT repair?
0-6 weeks
what are the goals of phase 2 RCT repair?
ROM
NM control
what are the interventions of phase 2 RCT repair?
ext/IR/horizontal adduction stretch
submax MR for ER/IR (supported)
scapular PREs
ALL UNDER 90 DEG
t/f: all interventions during phase 2 RCT repairs should be under 90 deg of shoulder motion
true
when is phase 2 RCT repair?
6-12 weeks
what are the goals of phase 3 RCT repair?
full ROM
NM control
improve endurance
return to fxn
what are the interventions of phase 3 RCT repair?
PREs for adb, flex, ER at 45 deg in POS (supported)
MR ER/IR and delts
when is phase 3 RCT repair?
12-16 weeks
what are the goals of phase 4 RCT repair?
return for fxn
prevention
what are the interventions of phase 4 RCT repair?
bodyblade in elevated positions
sport-specific training
when is phase 4 RCT repair?
16 weeks to 6 months
does RCT or tendinopathy have more specific protocol that is more gradual with stresses on the RC?
RCT
how is GH instability classified?
by frequency, magnitude, direction, and origin
what is the difference bw dislocation and subluxation?
dislocation comes out completely, but subluxation comes out partially and goes back in
what % of GH instability is anterior GH instability?
80%
what kind of GH instability is the most common?
anterior
order the GH instabilities from most to least common: inferior, anterior, MDI (multidirectional instability), posterior
anterior>inferior>posterior>MDI
what % of those >30 y/o have GH instability?
> 79%
what % of those >40 y/o have GH instability?
15%
why do people have less GH instability as they age?
bc the structures of the shoulder tighten up
85% of anterior dislocations of the shoulder involve RCT in populations over the age of ____
40 y/o
what tests would be positive with GH instability?
(+) apprehension
(+) relocation
(+) sulcus
what are the conservative interventions for GH instability?
sling in protective phase
mobilization of posterior and inferior capsule bc they tend to be tight
stretch posterior cuff (sleeper stretch)
PREs for the RC
normalize ST, AC, SC mechanics
how can we stretch the posterior cuff?
sleeper stretch
what portions of the shoulder tend to be tight in GH instability?
posterior and inferior
t/f: a tight posterior capsule puts the shoulder in ER and stresses the anterior capsule
true
what does TUBS stand for?
Traumatic Unidirectional instability w/Bankart lesion requiring Surgery
what is a Bankart lesion?
avulsion of the anterior-inferior labrum from the glenoid rim and requires surgical stabilization
t/f: Bankart lesions require surgical stabilization
true
what is a Hill-Sachs lesion?
compression fx of the posterior humeral head where the head impacts the inferior glenoid rim
what is a Bankart repair?
reattachment of the labrum and GH ligs to the anterior glenoid
detachment/reattachment of the subscapularis
what motion tends to be limited post Bankart repair bc the subscap is detached and reattached?
ER
how long is ER usually limited post Bankart repair?
6-8 weeks
does a Bankart repair tighten the anterior or posterior capsule?
anterior capsule
t/f: we often want a little tightness following repairs to prevent dislocation in the future
true
when is phase 1 Bankart repair?
0-4 weeks
what are the goals of phase 1 Bankart lesion repair?
pt ed
controlling pain
ROM
what are the interventions day 1 post-op Bankart lesion repair?
precautions
pendulums
distal AROM
ice
what are the interventions day 7-10 post op Bankart lesion repair?
stretch for flex/ER at 45 deg in POS (no >30 deg)
when is phase 2 Bankart lesion repair?
4-6 weeks
what are the goals of phase 2 Bankart lesion repair?
normalize GH and ST arthrokinematics
increased strength
what are the interventions of phase 2 Bankart lesion repair?
stretch for ext/IR/hor add
MR for stabilization
PREs for IR/ER/ext
shrugs
retractions
when is phase 3 Bankart lesion repair?
6-12 weeks
what are the goals of phase 3 Bankart lesion repair?
increased RC, delts, and ST muscle strength
PREs in provocative positions
what are the interventions for phase 3 Bankart lesion repair?
PREs for abd/flex/ER at 45 deg POS
PREs into provocative positions
bodyblade progression
plyoball (chest press)
when is phase 4 Bankart lesion repair?
12-16 weeks
what are the goals of phase 4 Bankart lesion repair?
return to fxn
what are the interventions for phase 4 Bankart lesion repair?
OH bodyblade
plyoball throwing
sport-specific training
what does AMBRI stand for?
Atraumatic, Multidirectional instability, Bilateral, Rehab, Inferior (anterior) capsular shift
what causes AMBRI?
systemic laxity (born loose)
t/f: AMBRI tends to be more amenable to rehab and conservative treatment
true
what may progressive laxity due to gradual reduction in muscle fxn lead to?
AMBRI
what symptoms does AMRBI produce?
impingement-like s/s w/abduction and ER
AMBRI may result in what conditions?
degenerative arthritis or RCT
t/f: AMBRI is an anterior/inferior capsular shift
true
what is the “pants over vest” treatment for AMBRI?
closure of the rotator interval bw the subscap and the supraspinatus
is conservative or surgical management of AMBRI more effective?
conservative management
what can we work on in AMBRI?
limiting ROM
proprioception
shoulder mechanics
ST/GH rhythm
what are systemic contributors to adhesive capsulitis?
DM
hypo/hyperthyroidism
hypoadrenalism
what are the extrinsic contributors to adhesive capsulitis?
cardiopulmonary disease
cervical disc dysfxn
CVA
humeral fx
Parkinsonism
what are the intrinsic contributors to adhesive capsulitis?
RC tendinitis
RCT
biceps tendinitis
calcific tendinitis
AC arthritis
t/f: adhesive capsulitis is an insidious onset inflammatory disorder
true
is there usually a known major event that causes adhesive capsulitis?
no, the pt usually didn’t do anything or had a really minor injury
what is adhesive capsulitis?
a cascade of inflammation w/subsequent fibrosis
what are the s/s of primary adhesive capsulitis?
idiopathic and progressive
gradual loss of ER
progressive loss of fxn
inflammation and pain w/muscles guarding
compensatory scapular motion (scap engages too early)
resolution of pain with stiff shoulder
primary adhesive capsulitis results in a gradual loss of what motion?
ER
what are the risk factors for adhesive capsulitis?
female
over 40 y/o
trauma
DM
prolonged immobilization
thyroid disease
stroke
MI
psychosocial overlay
autoimmune disease
post-menopausal
what are the s/s of stage 1 adhesive capsulitis?
mild impingement-like symptoms
<3 months
empty>capsular end feel
development of capsular pattern (ER>abd>IR)
what is the capsular pattern in stage 1 adhesive capsulitis?
ER>abd>IR
is there more of an empty or capsular end feel with stage 1 adhesive capsulitis?
empty end feel
how long ago do symptoms start with stage 1 adhesive capsulitis?
<3 months ago
what are the s/s of stage 2 adhesive capsulitis?
TTT over anterior shoulder w/radiation into delts insertion
improved pain but no change in ROM post injection
decreased ROM in all planes
loss of capsular volume
in stage 2 adhesive capsulitis, where is it tender?
over the anterior shoulder w/radiation into the delts insertion
when is stage 3 adhesive capsulitis?
9-14 months after onset
what stage of adhesive capsulitis is marked by severe pain w/resolution into extreme stiffness?
stage 3 adhesive capsulitis
what are the s/s of stage 3 adhesive capsulitis?
severe pain w/resolution into extreme stiffness
poor SH rhythm w/UT dominance
decreased inferior GH glide
what stage of adhesive capulitis is the “thawing stage”?
stage 4
why is stage 4 adhesive capsulitis called the “thawing stage”?
bc things are calming down and ROM is increasing
what GH glide is decreased in stage 3 adhesive capsulitis?
inferior GH glide
what are the s/s of stage 4 adhesive capsulitis?
some return of motion
capsular end feel and pattern
radiograph=disuse osteopenia
MRI=increased perfusion to synovium
arthrogram=reduced axillary fold
what would a radiograph reveal in stage 4 adhesive capsulitis?
disuse osteopenia
what would an MRI reveal in stage 4 adhesive capsulitis?
increased perfusion to synovium
what would an arthrogram reveal in stage 4 adhesive capsulitis?
reduced axillary fold
what are the goals of interventions for adhesive capsulitis?
controlled stress to restricted tissues through mobilization and stretching
t/f: adhesive capsulitis is self-limiting with gradual return to full mobility in 18 months to 3 years
true
at 7 years after adhesive capsulitis, 30% of pts have decreased ____ and 50% have ____ and ____
mobility, pain, stiffness
success of corticosteroid injections for adhesive capsulitis depends on what?
duration of symptoms
what is the goal of corticosteroid injections for adhesive capsulitis?
to limit synovitis and subsequent fibrosis
when is MUA (manipulation under anesthesia) or MUGA (manipulation under general anesthesia) used for adhesive capsulitis?
if conservative measures fail
what conditions would indicate that we should avoid MUA/MUGA?
osteopenia
recent RCT repair
fx
neurologic injury
instability
what is a SLAP lesion?
superior labral tears anterior to posterior
where are SLAP lesions?
10-2 o’clock
what part of the labrum is most susceptible to injury due to its mobility and close association with the LHB tendon?
superior labrum
t/f: SLAP lesions may occur in combo with other impairments during dislocation
true
SLAP lesions are usually due to what?
FOOSH
sudden traction forces
instability
what is the most common MOI of SLAP lesions?
falls (31%)
what is the second most common MOI of SLAP lesions?
dislocation (19%)
what is the third most common MOI of SLAP lesions?
lifting (16%)
what is a type 1 SLAP lesion?
fraying w/reduction in hor abd, ER w/forearm pronated
what is a type 2 SLAP lesion?
detachment of the labrum and biceps tendon anchor w/loss of stabilization
what is a type 3 SLAP lesion?
vertical tear of the labrum (like a bucket handle)
what is a type 4 SLAP lesion?
extension of tear to the biceps tendon which displaces into GH jt
what are the special tests for SLAP lesions/glenoid labrum?
O’Brien test
Crank test (and Kim test)
biceps load test
how do we perform the O’Brien test?
in sitting, flex 90 deg and IR the arm then flex 90 deg and ER the arm with 10 deg hor add and resist shoulder flexion
what is a positive O’Brien test?
IR>ER pain and weakness
pain inside=SLAP
pain on top=AC jt
how do we perform the Crank test?
in sitting, put the arm into 160 deg elevation w/elbow flexion, some deg of shoulder stabilization with the other hand, and compression with ER/IR
what is a positive Crank test?
pain
how do we perform the Kim test?
in sitting, put them arm in 130 deg in POS (plane of scap) with elbow flexion and apply compression
what is a positive Kim test?
pain
how do we perform the biceps load test?
in supine, abduct the shoulder to 90 deg, ER, and supinate with the palm facing the head in supine, and resist elbow flexion
what is a positive biceps load test?
pain
t/f: the diagnosis of glenoid labrum dysfxn is similar to RC pathology
true
how are glenoid labrum lesions diagnosed?
(+) special tests for the labrum
t/f: interventions for glenoid labrum lesions should address underlying instability
true
does a labral repair or debridement have more favorable outcomes?
labral repair
why are SLAP lesions hard to dx?
bc there is not a lot of weakness, nondescript shoulder pain, (+) labral tests, and instability at the shoulder
what nerves are most at risk in the shoulder for peripheral nerve entrapment?
long thoracic nerve
axillary nerve
spinal accessory nerve
suprascapular nerves
what muscle is innervated by the long thoracic nerve?
serratus anterior (SA)
what muscles are innervated by the axillary nerve?
delts
teres minor
what muscles are innervated by the spinal accessory nerve?
traps
SCM
what muscles are innervated by the suprascapular nerve?
suprapsinatus
infraspinatus
SA weakess is prominent in the ____ plane, while UT weakness is prominent in the ___ plane
sagittal, frontal
is the vascular or neurogenic aspects of thoracic outlet syndrome (TOS) easier to dx?
vascular bc there are no specific tests for the neurogenic aspects
t/f: TOS is a dx of exclusion
true
where are paresthesia in TOS?
non-dermatomal distribution
where can there be pain in TOS?
traps
shoulder/arm
supraclavicular region
chest
occipital HA
all 5 digits
digits 4/5
digits 1/3
what muscles can cause pinching points in TOS?
scalenes
pec minor
what are the special tests for TOS?
Adson test
Allen test
ROOS test
Wright test
Military press test
how do we perform the Adson test?
in sitting stabilize the scap, palpate the radial pulse, move the arm into abd, ER, ext and have the pt look at the arm and hold their breath to feel if the pulse changes
what is a positive Adson test?
change in pulse, discoloration, pain
how do we perform the Allen test?
in sitting, palpate the radial pulse, bring the arm into 90 deg abd and elbow flexion and tell the pt to look away from the arm and hold their breath to feel for changes in pulse
what is a positive Allen test?
change in pulse, discoloration, pain
how do we perform the ROOS test?
in sitting or standing, raise the BL shoulder to 90 deg abduction, ER, and flex the elbows and open and close the hands for 3 minutes
what is a positive ROOS test?
discoloration, pain, paresthesia
how do we perform the Wright test?
in sitting, palpate the radial pulse and bring the arm into 180 deg ER and take a deep breath
what is a positive Wright test?
discoloration, pain, change in pulse
how do we perform the Military press test?
in standing, palpate the radial pulse and retract the shoulders in exaggerated military posture with palms facing out
what is a positive Military press test?
discoloration, pain, paresthesia
what is an intervention for TOS?
1st rib depression mobilization
how do we perform 1st rib depression mobilization?
have the pt in sitting and the therapist in 1/2 kneeling on the table with one hand controlling the head and the other MCP on sup aspect of the 1st rib
move the head into SB as force is applied to an inf direction to the 1st rib
