Updates, figures and tables Flashcards
resting position of the SC joint
SC joint (clavicle relative to the sternum) a. Retraction – 20 from the frontal plane, motion in the horizontal plane b. Elevation – 5 degrees from the horizontal plane, motion in the frontal plane c. Rotation – 0 degrees from the horizontal plane, motion in sagittal plane Ludewig. “Motion of the shoulder complex during multiplanar humeral elevation.” (2009)
resting position of the AC joint
AC (scapular relative to the clavicle) a. IR – 60 from to the frontal plane, motion in the horizontal plane b. Upward rotation – 2 from to the horizontal plane, motion in the frontal plane c. Anterior tilt – 8 from the frontal plane, motion in the sagittal plan Ludewig. “Motion of the shoulder complex during multiplanar humeral elevation.” (2009)
Describe the motion of the SC joint during arm elevation 0-120
- Retraction – increases 16 (23 to 39) peak abd 44 flex 32 - Elevation – increases 6 (11 to 17), peak abd 20 flex 14 - Posterior rotation – increases 31 (starting form 0) peak abd=flex Ludewig. “Motion of the shoulder complex during multiplanar humeral elevation.” (2009)
Resting position of the scapulothoracic joint
Scapulothoracic (scapular relative to the thorax) a. IR (winging) – 41 from the frontal plane, motion in the horizontal plane b. Upward rotation – 5 from the sagittal plane, motion in the frontal plane c. Anterior tilt – 13 from the frontal plane, motion in the sagittal plane Ludewig. “Motion of the shoulder complex during multiplanar humeral elevation.” (2009)
Describe SC arthokinematics 0-120
- motion of the clavicle relative the the sternum
- retraction horizontal plane - flex 22 (-18 to -32); scap 12 (-24 to -36); abd 14 (-28 to -42)
- elevation frontal plane of motion - flex 5 (10-15); scap 5 (12-17); abd 6 (14-20)
- posterior rotation sagital plane motion - flex, scap and abd 31 (0-31)
What are the two openings in the shoulder joint capsule?
- bewteen the humeral tuberlces
- capsule and subscapularis bursa
Describe the angle of inclination of the scapular glenoid
- typically 7 degrees from vertical
- But can be flatter or stepper angles
what is the normal distance of the medial scapula to the SPs
5 cm
How does the AC articular surfaces change with age?
- acromial side fo the articlaru catilage change to fibocartilage by age 17
- clavicular side of the articular cartilage changes to fibrocartilabe by age 24
What motions does the coracoclavicular ligments resist?
- Conoid elevation and protraction
- trapezoid - elevation and protraction as well as AC joint compression
What ligament contributes to the rotation of the clavicle during arm elevation?
- Both the anterior and posterior bundles fo the costoclavicular ligament
Descirbe the force couple of the deltoid and RTC
- RTC creates compression of the humeral head in the glenoid
- deltoid pulls the humerus up
- RTC is most active in mid ranges with capsule is most lax
What are the benefit of the serratus and trap force couple
- rotation of scapula while maintaining the glenoid aligment
- matain effecient length tension relationship for the deltoid
- prevent RTC impingment
- provide a stable scapular base for arm movment
Describe the axis of rotation of the scapula during abduction
- beginng range axis of rotation near the medial border at the level of the spine of the scapula
- moves lateral towards the AC joint
Describe the RTC A/P force couple
- anterior subscap and posterior infrapinatus/teres minor
- provide superior migration stability
- provide glenoid/humeral head comrpession/centration
What are the evidnce informed ways of scribing scapular motion impairments
- Kibler’s (1) inferior angle (2) medial border (3) superior elevation
- McClure yes/no dyskninesia present
What Special tests could you use to confirm scapular dyskinesia
- Kiblers Scapular assistance test - manually assist the scapula into upward rotation to assess the impact on symptoms
- Kiberse scapular retraction test - manually retract the scapular as the patient goes into the 90/90 abduction postion and assess symptom reponse
- flip test - manually resist shoulder ER from the GH open pack position observing for scapular tilt
What are the key mechanical impairments in RTC injury
- anterior translation of the humeral head
- superior migration of the humeral head
What is posterior impingment of the shoulder
Max ER in an abudcted position with can cause an impingment of the RTC tendons between humberal head and glenoid rim
What are the best test position to isolate supraspinatus
- empty can
- full can
- champagne toast
what is the best position to isolate infraspinatus
0 degree abduction and 45 ER
best position for isolating subscap
lift off position
What are some special test for shoulder impingment
- Neer
- HK
- force IR in abduction
- cross arm
- Yocum (active raise of elbow in cross arm position
What are the most common models of shoulder pathology
- Impingment
- instability/loose joint
- Labral tear
- Degenerative changes
What are some common special tests for confirming shoulder instability/loose joint
- MDI sulcus sign
- Supine GH glides for inferior (90 degree), middle (60 degrees) and superior GH ligaments (30 degrees)
- Subluxation relocation test - supine 90 max position primary pain produced with ant glide or relieved with posterior glide, can repeat at 110 or 120 degree
What is the Beighton scale?
- Passive hyper extension of 5th metacarpal
- passive thumb opposition to the forarm
- elbow hyper extension
- knee hyper extension
- plams flat with trunk flexion
2-4/9 measures postive suggestive hypermobility
What types of tears can occur with the labrum
- transvere tears
- longitudinal tears
- flap tears
- horizontal cleavage tears
- fibrillated tears
60% Ant-sup region, 18% post-sup region, 22% multiple locations
What is the deiffernce between Bankart and SLAP lesion?
- Bankart - anterior to inferior
- SLAP - superior ant to poster
- type II SLAP - “peel back” as the arm is brought back into max abd and ER the superior labrum and biceps peels back off the bone
what are some special tests for labral pathology
Grind type tests
- clunk
- circumduction
- compression rotation
- crank test
Muslce load test
- O’Brian active compression (bicep test with palm up versus arm down)
- Mimori test
- biceps load test
- ER supination test (peel back position)
What are the standard x-ray views of the shoulder
- A/P - humeral head shoulder slightly overlap glenoid fossa and there should be about 7-8 mm between humeral head and acromium
- Y view
- Axillary view
What value does the CT scan have
- show subtle or complex fractures
- good for view loose bodies and arthric changes
- good for view Hill-Sach or reverse Hill-Sach lesion
What is the difference between primary and secondary imingment
- primary - direct compression of the RTC
- secondary - results from underlying GH instability
What can the humeral head imping against
- anterior third of the acromium
- coracoaromial ligament
- coracoid
- AC joint
What are Neer’s stage of imingement
- edema and hemorrhage
- fibrosis and tendonitis
- bone spures and tendon rupture
Describe the AC joint kinematics 0-120
- motion of the clavicle relative the the scapula
- Interanl rotation (winging) - flex 9 (57 to 66); scap 8 (57 to 65); abd 13 (55 to 63)
- upward rotation frontal plane of motion - flex 8 (8-16); scap 12 (4-16); abd 14 (3-17)
- tilting sagital plane motion - flex, scap and abd 31 (3 atnerio 12 posterior)
Desribe the arthokinematics of the scapulothoraic joint 20-120
- motion of the scapular relative to the thorax
- Interanl rotation (winging) - flex 5 (43 to 48@90); scap 1 (37 to 38@40-100); abd 30 with no change
- upward rotation frontal plane of motion - 40 (10-50
- tilting sagital plane motion - flex, scap and abd 9 (12 anterior 3 posterior)
Describe GH arthrokinematics 20-120
- motion of the humerus relative the the scapula
- elevation - flex, scap and abd 80 (0-80)
- horz add/abd - flex 20 (10-30@80 ant); scap 0; abd 20 (0-20@80)
- External rotation - starte flex 11, scap 32 and abd 50 all end at 62 degree
what are the differnt types of partial thickness RTC tears
- superior surface from mechanical compression of the subacromial space
- undersurface typically found in throwers with shoulder instability impairments (capsule, labrum, etc)
What are the differnt sizes of RTC full thickness tears
- samll 1cm or less
- medium 1-3 cm
- large 3-5 cm
- massive 5 cm or greater
What the the key principles for post operative RTC recovery
- Recongition of the tear pattern
- type of surgical fixation
- restoration of the foot print
What are the typical types of RTC tear patterns
- completer tear are typically
- crescent
- U-shapred
Describe a crescent shapred RTC tear
- does usally retract far form the greater tuberosity
- usally repaired directly back to the bone
- bone debridement is required to get good healing
- typically occurs in a transvere direction to the longitudnal axis of the tendon
Describe U-shpared RTC tears
- longitudnal to the RTC tendon and transverse to the tendon
Describe RTC repair suture and anchor placement
- Three types of sutures: simple matress and combination
- secturity of the sutures is most important (ie good knots)
- anchors are placed at 45 degree angles about 4-5mm fomr the articular margin and can be single or double row
- double rows provide a greater footprint
- Sutures bridges or tranosseous equivolents link the two rows and increase footprint
Desrbie the supraspinatus foot print
- area of the greater tuberosity
- typically 12mm sagittal plane by 24mm frontal plane
Is the supraspinatus undermore tension with IR or ER when the GH is in 30 degree
- IR places more tension
- ER actuall decreased tension at 30 and 60 degree
Cadver model
What has greater muscle activiation - supine PROM or seated pulleys
seated pulleys
About how long does it take for soft tissue repairs to gain adequate tensile strength to start indirect strengthending, light direct loading, light strengthening and maximal direct
- Indirect - 3-6
- direct loading - 6-8
- direct light strengthening 10 weeks
- max 12 weeks
Descirbe the RTC activation pattern in CKC weight shifts and wrist strengthening exercises
- CKC - 10% of a RTC MVC
- wrist - 5% of a RTC MVC
What perscent of shoulder instabilities are posterior
2-5%
Shoulder instaiblity is typically classifed in what 5 ways?
- frequency - acute, recurrent, chronic
- etiolgy - traumatic, atraumatic, microtruama (overuse), congenital, neuromuscular
- volition - volutary or involuntary
- direction
- degree - dislocation, subluxation, micro (transient)
How should your expect ROM to progress following (1) capusluar shift.plication (2) Bankart (3) anterior capusel repair (4) SLAP
- capsular shift - full range by 10-12 weeks with ER at neutral progressing most slow
- Bankart - apprach full range by 10-12 weeks with flex and ER in all planes taking 12+ weeks
- anterior capsule repair - full ROM by 10-12 week
- SLAP - full ROM aby 12 weeks with ER and IR coming along most slowly
What are the differetn types of SLAP tears
- type I - significnat fraying or degenration of the labrum
- type II - detachement of the of the superior labrum and biceps from the glenoid rim
- type III - bucket handle tearing of the labrum
- type IV - bucket handle tear into the substance of the biceps tendon
How do the different ligament of the AC joint impact it mechanics
- AC ligaments - staiblize A/P motion
- coricoclavicular - vertical stability
- conoid - anterior and superior rotation
What class of AC joint injury has a visible step off
class III
Describe the surgical options for AC joint injury
- preference is considervative because it is a trough joint to repair and outcomes are scetchy
- primary fixation with sutures and wires
- priamry fixation of the CC interval only
- distalc clavical resection without stabilization of the joints
- muscle transfer
what are some Risk factors of frozen shoulder
- elevated serum cytokine levels
- female
- between ago of 40-59
- family history
- HLA-B27 postive
- white
- DM
- thryoid disease
- coronary artery disease
- dupuytren’s disease
Imgaing of the frozen shoulder reveals what changes
- coracohumeral ligmant thickending greater than 4 mm
- capsule thickness greater than 7mm
how do croticosteriods impact Frozen shoulder?
- decrease symptoms in the first 3-6 weeks
- limited long term impact
What system problems can cause inflammtion in joints?
- RA
- ankulosing spoldylitis
- SA
- alcholism
- sickle cell
- gaucher disease
