UE - Shoulder Region Flashcards
Pigeon chest sternum deformity
Sternum is displaced?
Pectus carinatum
displaced anteriorly and inferiorly
Sternum aka?
T2
T4/T5 OR 2ND RIB
T6
T10
T9
jugular notch
sternal angle of louie
xiphoid dermatomal
xiphoid anatomical
xiphisternal
Funnel chest
displacement?
pectus excavatum
displaced posteriorly, overgrowth ribs
Barrel chest
Increase in?
sternum displaced?
increased AP diameter
displaced superiorly
Latissimus Dorsi
Aka:
O
I
N
A
Aka: broadest ms, swimmer’s ms
Important crutch walking ms
O: Iliac crest, L5-T7 SP, Inf angle of scap
I: Floor of bicipital groove
N: Thoracodorsal nn
A: EXADIR
Latissimus Dorsi
How to check for LOM:
- Supine hooklying – PPT
- B arm elevate 180 c ER
(+): inability to perform or APT
Indic: Tight LD
Latissimus Stretching
Stabilize Sup aspect of pelvis OR Lat
aspect of thorax
Bring Sh to FABER
Teres Major Stretching
Stabilize Axillary border of Scap
Bring Sh to FABER
Levator Scapulae
Nerve?
Action?
How to isolate contraction?
Stretching?
N: Dorsal scapular nn
A: Elevation & Scapular DR
How to isolate contraction:
Forearm at the back then shrug
Stretching: C/L LF, C/L Rot
Michael Jackson
Rhomboids
Nerve?
Action?
Strength testing?
N: DSN
A: Scap Add/Retraction & DR
- raise hand away from back
Deltoids
Active in all Sh motions except?
Nerve?
Action?
Active in all Sh motions except ADDUCTION
N: Axillary nn
A: Ant – Flex & IR
Mid – pure Abd
Post – Ext & ER
ACCESSORY JOINTMOTION
0
1 –
2 –
3 –
4 –
5 –
6 –
0- ankylosis
1 – Considerable hypomobility
2 – Slightly hypomobility
3 – Normal
4 – Slightly hypermobility
5 – Considerable hypermobility
6 – unstable joint
TRUE RIBS:
* FALSE RIBS:
* FLOATING RIBS:
TRUE RIBS: 1-7
* FALSE RIBS: 8-10
* FLOATING RIBS: 11-12
3 JOINTS Ribs
Costotransverse Joint
= Ribs + TP
Costochondral Joint
= Ribs + cartilage
Costovertebral Joint
= Ribs + vertebra
Ct
Cc
Cv
Murphy’s Percussion Test
aka?
Procedure?
(+)
Indication
a.k.a. test for costovertebral tenderness
Px: Sitting/Prone
Percuss at CV angle (12th rib &
V column)
(+): back/flank pain
Indic: kidney/renal dysfxn
Clavicle (Collar Bone)
Orientation?
MOI
Orientation:
Laterally – concave forward
Medially – convex forward
MOI: FOOSH
Most commonly fractured bone?
Clavicle (Collar Bone)
Scapula (Shoulder Blade)
Function:
Orientation
Glenoid Fossa:
Humeral Head:
Function: attachment to many ms
Orientation
Glenoid Fossa: SAL
Humeral Head: MPS
Scapula (Shoulder Blade)
(N) distance from vertebral body:
Acromion:
Coracoid process:
Suprascapular notch:
(N) distance from vertebral body:
6 cm/ 2-3fingerbreadths
Acromion: highest point of shoulder
Coracoid process:
-pecs Mn insertion
-SA of biceps origin
Suprascapular notch:
Scapula (Shoulder Blade) Landmarks:
T2-
T3-
T7-
T2-superior angle
T3-spine
T7-inferior angle
Humerus
Function:
Neck-shaft angle:
Crutch Palsy
Acute =
Chronic =
Surgical Neck:
1
2
Spiral Groove:
1
2
Ulnar Groove:
Function: attachment to many ms
Neck-shaft angle: 135 degrees
Crutch Palsy: Acute = Axilllary nn
: Chronic = Radial nn
Surgical Neck:
-Common site of stable Fx
-Axillary nn
Spiral Groove:
-Radial nn
-(Triceps spared)
Ulnar Groove: Ulnar nn
X-RAY Identification
Least to Highest
AIR
FAT
WATER
SOFT TISSUE
BONE
METAL IMPLANTS
Joints of the shoulder region
1.
2.
3.
4.
- SC - sternoclavicular
- AC - acromioclavicular
- GH - glenohumeral
- ST – scapulothoracic (not a truejoint)
Sternoclavicular Joint
Type of joint?
Degrees of freedom?
MOI?
Special Test?
Joint Mob:
Protract/Retract:
Elevation /Depression:
Type of joint: Saddle
Degrees of freedom:
-Elevation/Depression
-Protraction/Retraction
-Rotation: (abd beyond 90)
MOI: Fall on Lat aspect of Sh
ST: AC Crossover Test
Joint Mob:
Protract/Retract: Same
Elevation /Depression: opposite
Sternoclavicular Joint
OPP
CPP
CP
Open Pack Position: Arms at side
Close Pack Position: Full Elevation and Protraction
Capsular Pattern: Pain at extremes of range of motion
especially horizontal adduction and full elevation
Ligaments of the Sternoclavicular Joint
Limits?
1.
2.
3.
4.
Limits Clavicle
1. Interclavicular – Limits depression
2. Ant SC ligament – Limits retraction
3. Post SC ligament –Limits protraction
4. Costoclavicular ligament
- Most impt (strongest)
- Both – Limits elevation
- Ant band – Limits retraction
- Post band – Limits protraction
Supraspinatus
Nerve?
Action?
N: Suprascapular nn
A: Initiates Abd
**prone to injury
(supraspinatus tendinitis)
Supraspinatus/Empty Can/Jobe Test
1st
2nd
(+):
Indic
1st = Abd 90 c neutral rot then
PT resist Abd
2nd = IR & angled forward to
30 then PT resist Abd
(+): weakness or pain
Indic: Supraspinatus ms or
tendon tear or Suprascapular
nn neuropathy
Drop arm test/
Codman test
1st
(+):
Indic
Abd 90
❑ Ask px to slowly drop the arm
❑ (+) unable to slowly drop = no
eccentrics of rotator cuff
❑ Indic: RC tear
Infraspinatus
Nerve?
Action?
N: Suprascapular nn
A: ER esp. strongest if arms
are at the sides
Infraspinatus Test:
Procedure
(+):
Indic
❑ Arms at the side, elbow 90, Sh
IR 45 degrees
❑ PT applies medial rotation force
while px resists by doing ER
❑ (+): pain or inability to resist IR
❑ Indic: Infraspinatus strain
Lateral Rotation Lag Sign
(Infrapinatus “Spring Back” Test)
Procedure
(+):
Indic
❑ T. Minor/ Infraspinatus
❑ Sitting/Standing
❑ PT passively Abd Sh to 90
and ER to end range
❑ Ask px to hold the position
❑ (+) inability or hand “springs
back” or “lags” ant to the
midline
❑ Infra/T. Minor weakness
Teres Minor
Nerve?
Action?
N: Axillary nn
A: ER
To isolate: Elbow 90, Sh Abd 90,
ER resist
Hornblower’s
Aka: Patte’s, Signe de Clairon Test
Procedure
(+):
Indic
Modification?
A:
❑ Sh 90 deg of scaption
❑ Ask px to ER against resistance
❑ (+): inability to perform
❑ Indic: T Minor tear
B: Modification
❑ Ask px to bring hand to mouth s Abd
❑ (+) Abd moment = (+) Hornblower sign
❑ Indic: Massive RC tear
Subscapularis
Nerve?
Action?
N: Upper & lower subscapular nn
A: IR
Lift-off sign/ Gerbers Test
Procedure
(+):
Indic
❑ Dorsum of hand at the back
❑ Lift hand away from the
back
❑ (+): inability to perform
❑ Indic: Subscapular lesion
Modified Lift-offsign or
Subscapularis/Medial Rotation - Spring Back/Lag Test
Procedure
(+):
Indic
❑ Passively IR at end range
❑ Ask px to hold position (A)
❑ (+): inability to hold position
or “springs back” ant (B)
❑ Indic: Subscapularis
affectation
Abdominal Compression Test
aka Belly Press / Napoleon Test
Procedure
(+):
Indic
❑ PT & px place hand at belly
❑ (+) inability to maintain pressure on
examiner’s hand
❑ (+) compensates thru wrist ext, Sh ext,
or moving of elbow forward
❑ Indic: Subscapularis tear
Holds the humeral head tightly against the glenoid to prevent subluxation when carrying weight in the hand
Rotator Cuff Dynamic Stabilization
Rotator Cuff Muscles?
- Supraspinatus
- Infraspinatus
- Teres minor
Teres Major
Nerve?
Action?
N: Lower subscapular nn
A: EXADIR
Biceps brachii
Nerve?
Action?
N: Musculocutaneous nn
A: Elbow flex, FA supination, &
weak Sh flex
May act as an Abd when Sh is in ER
Palpation: EXABER
May act as an Abd when Sh is in ER
Biceps brachii
Triceps Brachii
Nerve?
Action?
N: Radial nn
A: Elbow ext & weak Sh ext
Biceps brachii
2X?
4X?
2X Stronger than supinator at full elbow extension
4X Stronger than supinator at 90 deg elbow flexion
Supinator supinates best at full elbow ___________
Supinator supinates best at full elbow flexion
Ligaments of the Sternoclavicular Joint
1.
2.
3.
4.
- Interclavicular – limits depression
- Anterior SC ligament -limits retraction
- Posterior SC ligament - limit protraction
- Costoclavicular ligament
- BOTH: limits elevation
- Anterior band - retraction
- Posterior band – protraction
Acromioclavicular Joint
Type of joint:
Degrees of freedom: (3)
MOI:
LIGAMENTS:
Type of joint: Plane
Degrees of freedom:
Elevation/Depression
Abduction/Adduction
Rotation
MOI: Direct blow/trauma to the Sh
(Rugby players)
LIGAMENTS:
Anterior
Posterior
Coracoclavicular (strongest) – Trapezoid & Conoid
Acromioclavicular Joint
OPP:
CPP:
CP:
Painful Arc?
AC
GH
Open Pack Position: Arms at the side
Close Pack Position: 90 degrees of abduction
Capsular Pattern: Pain at extremes of range of motion
Painful Arc:
*AC
170-180 Abd
Last 10° of Abd
*GH: 60-120
Acromioclavicular Crossover
Aka:
Crossbody Test
Horizontal Adduction Test
Procedure
(+):
Indic
❑ Most sensitive (Gold Standard) for
AC Jt
❑ Actively reach opposite Sh OR
Passive F Flex & H Add
❑ (+): localized pain @ AC jt
❑ Can be (+) for SC patho (localized
pain @ SC jt)
Acromioclavicular Joint
OPP:
CPP:
CP:
Painful Arc AC:
Painful Arc GH:
Open Pack Position: Arms at the side
Close Pack Position: 90 degrees of abduction
Capsular Pattern: Pain at extremes of range of motion
Painful Arc:
*AC
-170-180 Abd
-Last 10° of Abd
*GH: 60-120
Acromioclavicular Crossover
Aka:
Crossbody Test
Horizontal Adduction Test
Procedure
(+):
Indic
❑ Most sensitive (Gold Standard) for
AC Jt
❑ Actively reach opposite Sh OR
Passive F Flex & H Add
❑ (+): localized pain @ AC jt
❑ Can be (+) for SC patho (localized
pain @ SC jt)
Rockwood Classification of AC Jt Injury
1.
2.
3.
4.
6.
Grade 1- sprained AC, intact CC
Grade 2- ruptured AC, sprained CC
Grade3-RupturedAC&CC
Grade4- Ruptured AC & CC (posteriorly displaced)
Grade5- Ruptured AC & CC (superiorly displaced)
Grade 6- Ruptured AC & CC (inferiorly displaced)
Deformity that causes the distal end of clavicle is superior to the acromion process
causes?
STEP DEFORMITY
Causes: Step deformity resulting from AC dislocation
Definition: (+) sulcus below the
acromion process
Causes:
SULCUS SIGN
Causes:
B. GH subluxation
(stroke/deltoid ms. paralysis)
C. Anterior dislocation at SC joint
Types of
Acromion
1.
2.
3.
4.
A. Flat
B. Curved – most common
C. Hooked–commonly linked c shoulder impingement (rot cuff tear)
D. Upturn/convex – least common
Glenohumeral Joint
Unstable d/t:
Dynamic Stability:
Static Stability:
Unstable d/t: Large HHead,
Small Glenoid Fossa
Dynamic Stability: Rot Cuff
Static Stability: Ligaments &
Labrum (deepens glenoid cavity)
GLENOHUMERAL JOINT
Type of Joint: Enarthrodial jt
OPP:
CPP:
CP:
Movements:
Type of Joint:
Open Packed Position: 55 Abd, 30 H Add
Close PackedPosition: 90 Abd, Full ER
Capsular Pattern: ER>Abd>IR = F
Movements:
Abduction/Adduction
Flexion/Extension
IR/ ER
GLENOHUMERAL JOINT
To increase flexion and IR =
To increase extension and ER =
To increase abduction =
**To increase ER in patients
with frozen shoulder =
To increase flexion and IR = posterior glide
To increase extension and ER = anterior glide
To increase abduction = inferior glide
**To increase ER in patients
with frozen shoulder = posterior glide
Ligaments limits
- SGHL–
- MGHL –
- IGHL
Ant:
Post: - CHL –
- SGHL– limitsER @ 0-45;
- MGHL – limits ER @ 45-60
- IGHL
Ant: limits ER 45-180
Post: limits IR 45-180 - CHL – limit ER 0-60
Scapulothoracic Joint
Aka:
Function:
MOVEMENTS:
Aka:
Scapulohumeral/Scapulocostal
*not a true joint
Function: Adds mobility to GH joint
➢ELEVATION/ DEPRESSION
➢PROTRACTION/ RETRACTION
➢UPWARD/ DOWNWARD ROTATION
➢Landmark: Glenoid Fossa
➢ANTERIOR and POSTERIOR
TILTING/TIPPING
➢Landmark: Superior Scapula
SCAPULOHUMERAL RHYTHM
REQUIREMENTS FOR FULL ARMELEVATION
* R –
* I –
* S –
* E –
Functions:
1.
2.
3.
- R – Rotation of the clavicle posteriorly
- I – Inferior translation of the HHead
- S – Scapular stabilization
- E – ER of the HHead
Functions:
1. Increase ROM of arm
2. Maintain articulation
3. Maintains length tension relationship
SCAPULOHUMERAL RHYTHM
Divided into 3 phases:
PHASE 1
(Setting phase)
PHASE 2
PHASE 3
Definition-GH-ST-Clavicle
Pure GH only – 0-30 – No ratio – 30 - Elev 0-5
30-90 2:1 – 40 – 20 Elev – 10-15
90-180 2:1 – 60 – 30 – Elev 15 Post Rot 30-50
Coracoacromial Arch
AKA:
Function:
1.
2.
3.
AKA: Suprahumeral arch
Function: Passageway of
important structures
- Supraspinatus tendon
- Subacromial bursa
(lubrication, ↓ friction during
Sh motion) - Long head of biceps
Lesser & greater tubercle
Holds long head of biceps with the help of _______ ligament.
Transverse humeral ligament
Speed’s Test
aka: Biceps or Straight-Arm Test
Procedure
(+):
Indic
❑ Maybe (+) in px c __________
❑ Resist F Flex while elbow ext &
FA supinated 1st
❑ then pronated
❑ (+): tenderness in bicipital
groove (esp. supination)
❑ Indic: Bicipital
Paratenonitis/tendinosis
❑ Maybe (+) in px c SLAP Type 2
lesion
LBC - Labral Biceps Complex
Yergason’s
❑ 1° tests the ability of _____ to hold the _______
❑ Palpate: _________
❑ 1st =
❑ 2nd =
❑ (+):
❑ (+): tenderness =
❑ 1° tests the ability of THL to hold the biceps tendon
❑ Palpate: bicipital groove
❑ 1st = Elbow flex 90, FA pronated, Sh IR (used to give way to step 2)
❑ 2nd = Px ER & supination c PT resist
❑ (+): popping out of biceps tendon from groove = Torn THL
❑ (+): tenderness = Bicipital paratenonitis
(+) = THL pathology
- Pectoralis Major
- Pectoralis Minor
Nerve?
Action?
- Pectoralis Major
N : Lateral & Med pectoral nn
A : FADIR (clavicular fiber) - Pectoralis Minor
N : Med pectoral nn
A : Elevates Ribs (Inspiration),
Ant tilting of the scapula,
Depress point of sh
Pectoralis Major Contracture Test
Procedure
(+):
Indic
Px position:
Supine
Clasps hands behind the head then
PT lowers the elbow (EXABER)
(+): elbows did not touch the table
Indic: Pecs Major tightness
Pectoralis Minor Contracture Test
Procedure
(+):
Indic
Px position:
Supine
Arms flexed 30 c bolster/foam roller
underneath then PT pushes coracoid
process towards table
(+): Scapula did not touch the table
Indic: Pecs Minor tightness
Pectoralis Minor
Active Stretching
- 3.
Pectoralis Minor
Active Stretching
- Elevate coracoid process
- Posterior tilting of scapula
- Exhalation
Serratus Anterior
Nerve?
Action?
- N: Long thoracic nn
- A: Protraction & UR scapula
Medial winging (open book)
Muscle involved:
Nerve involved:
Degrees:
Affected in:
Pt will have difficulty in:
Medial winging
Muscle involved: SA
Nerve involved: LTN
Degrees: >90 deg
Affected in: Radical Mastectomy
Pt will have difficulty in: combing hair
Lateral winging (closed door)
Muscle involved:
Nerve involved:
Degrees:
Affected in:
Pt will have difficulty in:
Muscle involved: Trapezius
Nerve involved: CN 11
Degrees: <90
Affected in:
Pt will have difficulty in:
Downward rotators?
Upward rotators?
Downward rotators
- Lev scap
- pecs minor
- rhomboids
Upward rotators?
- Upper and Lower Trapezius
- SA
Punch out test
❑ 1st =
PT applies
(+):
Indic:
❑ 2nd =
d/t _____palsy or ______
(+) winging =
(-) winging =
❑ 1st = F Flex 90 & IR
PT applies backward force
(+): winging
Indic: SA weakness
❑ 2nd = DDx if SA weakness d/t LTN palsy
or post instab
F Flex 90 & ER
(+) winging = LTN palsy
(-) winging = post instab
Trapezius
Nerve?
Action?
N: Spinal Accessory nn (CN XI)
A: U: Elevates scap
M: Retraction
L: Depresses scap
Latissimus Dorsi
Nerve?
Action?
Check for LOM:
1.
2.
(+):
N: Thoracodorsal nn
A: EXADIR
Check for LOM:
1. Supine hooklying – PPT
2. B arm elevate 180 c ER
(+): inability to perform or APT
Indic: Tight LD
(+) Tightness of Lats if there is lordosis
hooklying c Faber and standing
Biceps brachii
Nerve?
Action?
N: Musculocutaneous nn
A: Elbow flex, FA supination, &
weak Sh flex
May act as an Abd when Sh is in ER
Palpation: EXABER
Triceps Brachii
Nerve?
Action?
N: Radial nn
A: Elbow ext & weak Sh ext
Biceps Brachii
- Biceps as a FA ______________
- 2x stronger than Supinator ms at __________
- 4x stronger than Supinator ms at __________________
- Biceps as a FA supinator
- 2x stronger than Supinator ms at full elbow ext
- 4x stronger than Supinator ms at 90 deg elbow flex
Trapezius
MMT of
Upper trapz:
Lower trapz:
All fibers c SA –
U: Shrugs
M: prone, Abd 90 elbow flex 90 then ask
patient to retract
L: prone, thumbs up 120abd then ask
patient to retract
All fibers c SA – Scapular UR
