Shoulder w/o req'd readings Flashcards
Can shoulder special test structurally differentiate?
No, the full can and empty can tests activate 13 muscles
How many people in the general population have a rotator cuff tear?
22%
Of the people that have rotator cuff tears, how many are symptomatic?
Only 1/3 (asymptomatic tears are 2x as likely as symptomatic)
PT is as effective as surgery for what shoulder conditions?
Subacromial impingement syndrome, rotator cuff partial thickness tears
PT reduces the need for surgery by 75% in what kind of shoulder injury?
Atraumatic Full Thickness Tears
Where are shoulder symptoms coming from?
Mobility deficits, hypermobile instability, referred pain, psychosocial factors, soft tissues, posture?, peripheral or central sensitization
What are the 4 things to modify with shoulder symptom modification procedure?
Thoracic posture
Scapular Position
Humeral Head Position
Pain and symptom neuromodulation techniques
What are symptom neuromodulation techniques with shoulder symptom modification procedure?
Manual therapy
Modalities
Manipulation,
Is there a correlation between thoracic posture and pain?
No, but if it changes symptoms it becomes clinically relevant
Is shoulder pain correlated with scapular dyskinesis?
No, 67.2% of participants with shoulder pain and 61.8% of participants without shoulder pain demonstrated scapular dyskinesis.
What are typical deficits of a SICK scapula?
Decreased upward rotation
Increased internal rotation (medial border winging)
Increased anterior tilt
How do you change scapular position with shoulder symptom modification procedure?
Place the scapula in 1 of 4 movement planes:
-Elevation/depression
-Upward rotation
-Protraction/retraction
-Anterior/posterior tilt
Then allow it to move from the new position and see if it changes the symptoms
How do you correct scapular elevation with shoulder symptom modification procedure?
One hand in/under the axilla and the other thumb on the posterior axilla and then passively elevated until even with the other side. Patient then raises the arm and observe if there is a change in symptoms
How do you correct scapular upward rotation with shoulder symptom modification procedure?
Passively move the shoulder into upward rotation and then, without assisting or restricing, have the patient elevate their arm
How do you correct scapular posterior tilt with shoulder symptom modification procedure?
Top hand pull scapula into posterior tilt while bottom hand pushes on the inferior angle.
or
Grasp the acromion with the hand and use the forearm to posteriorly tilt
What do you do if the scapular position improves the functional movement?
Improve mobility and stability; mobility before stability
With shoulder symtpom modification procedure, if scapular positioning changes symptoms, how do you improve mobility?
Manual Therapy to the following:
-Pec Minor
-Upper Trapezius
-Subscapularis
-Rhomboids
-Levator Scapulae
Joint mobilizations for:
-Posterior capsule
-Scapular mobs in the restricted direction
With shoulder symtpom modification procedure, if scapular positioning changes symptoms, how do you improve stability?
Work the following:
-Posterior Cuff
-Serratus Anterior
-Lower Trapezius
-Other Scapular Muscles
Following Stability Principles:
-Motor Control
-Isolated Strengthening
-Endurance
-Neuromuscular Control
-Functional/Sport Specific
What shoulder muscles/structures do you consider if there is a lack of soft-tissue flexibility?
-Pec Minor
-Levator Scapulae
-Rhomboids
-Posterior Capsule
-Infraspinatus
-Latissimus Dorsi
How do you facilitate humeral depressors?
Shoulder is positioned with elbow bent just below point of symptoms, then performs 3 isometric contractions of 5-6 seconds into examiner or surface, arm is gently and passively lowered and movement retested
What are some manual techniques you can use to try to effect the shoulder symptoms?
Pair the provocative movement with:
-PA belt force
-AP belt force
-ER resistance
-IR resistance
Treatment to thoracic spine effects cervical impairments how?
Improves cervical ROM
Reduces cervical pain
Reduces cervical radiculopathy
C7-T1 hypomobility increase risk of what 3 things?
Neck Pain
Shoulder Pain
Hypermobility of T1-T2
C7-T1 Hypomobility is present in what percentage of acute shoulder pain? In chronic shoulder pain?
42%,
83%
What thoracic movement occurs with arm elevation?
Thoracic extension and ipsilateral side bending and rotation
Slouched posture/kyphosis is associated with?
Decreased arm elevation
Vascular/Arteriole presentation of Thoracic Outlet Syndrome represents what percentage of cases?
<1%
Vascular/Venous presentation of Thoracic Outlet Syndrome represents what percentage of cases?
2-3%
What are signs of vascular/arteriole thoracic outlet syndrome?
-Hand or digital ischemia with pain, parasthesia, coldness of color changes
-Decreased distal pulses, possible palpable tender mass in subclavian artery
What is the treatment of vascular/arteriole thoracic outlet syndrome?
-Immediate referral due to possible subclavian artery aneurysm, stenosis or distal emboli
-Possible that 1st rib resection may be part of treatment
What are signs of vascular/venous thoracic outlet syndrome?
-Neck and arm pain, arm swelling and cyanosis, some paresthesia
-Visual subcutaneous veins over shoulder and chest wall
What is the treatment of vascular/venous thoracic outlet syndrome?
-Referral secondaryto possible thrombosis in subclavian vein
-If Acute, thrombolysis of clot, 1st rib excision, or dilating stenosis with balloon angioplasty
If Chronic, no treatment
Neurological presentation of Thoracic Outlet Syndrome represents what percentage of cases?
95%
What are signs of neurological thoracic outlet syndrome?
-Neck, shoulder, and arm pain
-Typically presents in lower cervical nerves, C8-T1 including pain/paresthesia along ulnar border of forearm and hand
-Less freqent in upper cervical nerves of C5-C7; median nerve
What are symptoms of neurological thoracic outlet syndrome?
-Pain influenced by shoulder elevation and carrying objects
-Tenderness of anterior scalenes, upper trapezius, and anterior chest wall along pec minor
-1st rib elevation indicated by cervical rotation lateral flexion test
What are conservative care options of thoracic outlet syndrome?
-Education and behavior modification
-Egonomic and posture correction
-Relaxation exercises
-Manual therapy
-Nerve Glides
-Strethcing and strengthening exercises
What is the prognosis of neurological thoracic outlet syndrome?
Majority will succeed with conservative care
What are surgical care options for thoracic outlet syndrome?
If 3 months of conservitive care fails:
-First rib excision
-Excision of anterior scalenes
What are signs and symptoms of T4 syndrome?
-Upper extremity parasthesias and pain wtih or without head and neck pain
-Paresthesias in the distal fingers
-Glove-like numbness in the hand and forearm
-Weakness
-Handclumsiness
-Coldness
-Sense of fullness
-Tightness and deep pain
What causes T4 syndrome?
-Associated with hypomobile thoracic segments
-Sympathetic nervous system may provide a pathway for referral from thoracic spine to head and arms
What is treatment for T4 syndrome?
-Intramuscular spinal injections
-Manipulations
-Physical therapy
-T4 mobilizations
What is 2nd rib syndrome?
A sprain to the 2nd rib articulation
What are signs and symptoms of 2nd rib syndrome?
-Heavy limb and uselessness of arm
-Pain along posterolateral side of shoulder
-Mimics subacromial impingement syndrome
What is treatment for 2nd rib syndrome?
-C7-T3 mobilizations
-Strengthening of lower trapezius and serratus anterior
What is subacromial impingment syndrome?
Multi-factorial mechanical syndrome from primary factors of bony morphology of acromion with developmental spurring or secondary factors of poor mechanics due to weak rotator cuff muscles
What are signs and symptoms of subacromial impingement syndrome?
Pain, crepitus, stiffness, and weakness
What is the treatment for primary subacromial impingement?
For stage I: manual therapy and exercise
For stage II: manual therapy, exercise, possible surgery
For stage III: rotator cuff strengthening, joint mobilizations, surgery
What is the treatment for secondary subacromial impingement syndrome?
Proprioceptive, neuromuscular strengthening
What is the treatment for internal subacromial impingement syndrome?
Rehab or labral repair
How does exercise compare with manual therapy plus exercise for subacromial impingement syndrome?
Manual therapy plus exercise showed a 70% reduction in pain compared with 35% with exercise alone
Thoracic spine mobilization showed what effects related to shoulder pain?
-Reduced pain
-increase lower trapezius strength
CPR for thoracic manipulation?
-Pain-free shoulder flexion >127 degrees
-Shoulder internal rotation <53 degrees at 90 abduction
-Negative neer test
-Not taking medications for shoulder pain
-Symptoms less than 90 days
*89% chance of success with 3 or more
**Not validated
Cervicothoracic spine plays an integral role in?
Shoulder pain, range of motion, and strength
What leads to rotator cuff injury?
Abnormal Arthrokinematics
Outlet Stenosis
Aging: Altered Vascularity, Degeneration
Can be one or multifactorial
The rotator cuff counteracts the?
Deltoid
The supscapularis conteracts what in the transverse plane?
The Infraspinatus and teres minor
What happens if the force couple of the rotator cuff isn’t restricting the deltoid?
The humerus migrates superiorly; causing secondary impingement
What else causes secondary impingement besides a deficient rotator cuff?
Posterior capsule tightness, glenohumeral instability, and scapular instability
What is outlet stenosis?
Narrowing of the subacromial space; potentially causing spurring on the underside of the acromion
What type of acromion has the most downward curve of the acromion?
Type III
What is the test item cluster for full thickness rotator cuff tear?
-Drop Arm Sign
-Painful Arc (60-120 degrees of shoulder elevation)
-Pain, weakness, or lag with infraspinatus test
All 3 positive plus over 60 = LR 28; under 60 LR is 15.6
Where is a partial thickness rotator cuff tear?
Either humeral or acromial side
What are the sizes for Full Thickness Rotator Cuff Tears?
Small <1 cm
Medium 1-3 cm
Large 3-5 cm
Massive >5 cm
Which are more likely to have a better outcome? A Grade 1A or Grade 1B rotator cuff tear? (Also what are they?)
1B is a longitudinal or vertical tear and is more likely to have a better outcome; 1A is a horizontal tear
What do you need to do while rehabbing a rotator cuff tear?
Protect the remaining tissue and strengthen what’s in tact
What has been shown with the non-operative management of rotator cuff tendonitis and impingement?
Significant for pain reduction and improving function; not significant for range of motion or strength
Kuhn 2009 systematic review on RTC impingement
What are suggested for the 0-2 weeks after subacromial decompression?
No overhead movements
Ice 3-5x/day
Pendulums, cane exercises, isometrics, rhythmic stabilization
Avoid pushing down on a surface that may cause the shoulder to elevate
What types of surgery are there for rotator cuff injury?
Arthroscopic
Mini-open/deltoid splitting
Open with detachment of deltoid
Is there a difference between single row versus double row for rotator cuff repair?
No; but maybe quicker healing for double row (not statistically significant)
What are the factors to determine the rehab after a rotator cuff repair?
Surgical approach
Size of tear
Location of tear
Quality of soft tissue/bone
Quality of fixation
Why was rotator cuff repair PT “decelerated”?
Started to see more failures
Decelerated rehab increased stiffness
No long term reduction of shoulder ROM
Improved tendon healing
No difference at 12-month follow-up compared to accelerated rehab
What does level 1 and 2 rotator cuff repair evidence show?
-Do not use CPM unless women or >60 y/o
-No proof of an advantage of supervised over unsupervised rehab
Which shoulder instability category likely indicates surgery?
TUBS
