Uppers Shoulder Flashcards
1
Q
shoulder clinical anatomy
- static vs. dynamic stability
- common MOI
A
complex greatest ROM of any joint in the body static vs. dynamic stability -static: inert structures (labrum, ligaments, bony structures) -dynamic: muscles, nerves common MOI -direct force -indirect force --falling on an outstretched arm --overuse injury
2
Q
shoulder joints
A
sternoclavicular joint
acromioclavicular joint
glenohumeral joint
scapulathoracic articulation
3
Q
SC joint
- motions
- SC disc
A
only connection of upper extremity to axial skeleton gliding joint very little bony stability motions -elevation/depression -protraction/retraction -IR/ER SC disc -between distal end of clavicle and sternum -like the meniscus of the SC joint
4
Q
SC joint ligaments
A
A/P SC ligaments -prevents A/P displacement interclavicular ligament -attaches clavicles -attaches to superior border of sternum costoclavicular ligament -attaches to first rib
5
Q
AC joint
-motions
A
joint distal end of clavicle to acromion motions -IR/ER -upward/downward rotation -A/P scapular tipping
6
Q
AC joint ligaments
A
acromioclavicular
coracoacromial
coracoclavicular
-conoid and trapezoid
7
Q
GH joint
- type of joint
- motions
- combined movements
- angle of inclination
A
ball and socket joint -motion > stability motions -flexion and extension -abduction and adduction -internal and external rotation -horizontal abduction and adduction -circumduction over 16,000 combined movements angle of inclination -angle from shaft of humerus to head of humerus -130-150 degrees
8
Q
GH joint
- glenoid labrum
- joint capsule
- ligaments
A
glenoid labrum
-cartilage ring that runs around the edge of the glenoid fossa
-deepends socket of shoulder
–provides stability
-long head of biceps tendon attaches on the glenoid at the labrum
joint capsule
-volume of the joint capsule is twice the volume of the humeral head
–not much stability
ligaments
-GH ligaments
–superior, middle, and inferior
–actually thickenings of the joint capsule
-coracohumeral ligament
9
Q
GH joint
- coracoacromial arch
- plane of scapula
A
coracoacromial arch -formed by the coracoacromial ligament -protects the top of the humeral head -protects the rotator cuff tendons -protects the bursa plane of the scapula -the most functional plane of the rotator cuff is 30-45 degrees from the frontal plane
10
Q
scapulothoracic articulation
- scapular movement
- scapulothoracic rhythm
A
“false joint”
moves in response to other joints
requires great dynamic stability
scapular movement
-superior/inferior (elevation/depression)
-anterior/posterior (forward/backward tipping)
-upward/downward rotation
-ER/IR
-medial/lateral movement (protraction/retraction)
scapulothoracic rhythm
-GH and scapulothoracic articulation must function together
–2:1 ratio GH:STA
11
Q
bursae
A
subacromial bursa
-above supraspinatus tendon
-buffer between rotator cuff and acromion
subdeltoid bursa
12
Q
muscles acting on the scapula
- functions
- muscles
A
functions -control position of glenoid -fix the scapula to give a stable base of support for the rotator cuff muscles -rhomboid major and minor -levator scapulae -serratus anterior -trapezius -latissimus dorsi -pectoralis major -pectoralis minor
13
Q
rhomboids
A
downward rotation
retraction
elevation
14
Q
levator scapulae
A
elevation
retraction
upward rotation (small)
15
Q
serratus anterior
A
protraction
upward rotation
long thoracic nerve
16
Q
trapezius
A
upper -upward rotation -elevation middle -retraction lower -upward rotation -retraction -depression
17
Q
latissimus dorsi
A
depression (on scapula)
18
Q
pectoralis major
A
depression (on scapula)
19
Q
pectoralis minor
A
depression
20
Q
muscles acting on the humerus
A
rotator cuff -subscapularis -supraspinatus -teres minor -infraspinatus deltoid pectoralis major latissimus dorsi
21
Q
rotator cuff functions
A
subscap -IR - extension - horizontal adduction supraspinatus -abduction teres minor -ER - horizontal abduction infraspinatus -ER - horizontal abduction
22
Q
force couples
A
two muscles that pull in two different directions to provide stability
best example
-deltoid/rotator cuff
–deltoid pulls up on humerus
–rotator cuff pulls down on humerus
–both function to keep the humeral head depressed within the glenoid
23
Q
adhesive capsulitis
- MOI
- 4-step progression
- capsular pattern
- end-feel of shoulder
- Tx
- most common population
A
MOI -thickening (fibrosis) of the joint capsule 4-step progression -pain at deltoid insertion -night pain -pain at end range of motion (begin to see joint stiffness) -stiffness without pain capsular pattern -ER is the MOST limited -abduction is MODERATELY limited -IR is LESS limited end-feel of shoulder -IR/ER has hard/locking end feel Tx -will occasionally self-resolve, but not common -steriod injection -joint mobilizations occurs commonly post-op or after severe injury over the age of 50, white females
24
Q
GIRD
-total arc of motion
A
common in overhead athletes, especially baseball
15-20 degree deficit when compared bilaterally
total arc of motion
-typically someone may make up for a deficit in one direction with extra mobility in the other direction
risk for other injuries
Tx
-stretching and mobilization
25
why is the scapula important?
- "core of the shoulder"
- provides a stable base of support for the shoulder and arm
- large role in stabilizing humerus
- -position of scapula positions the humerus
26
scapular dyskinesis
```
poor scapular function
-abnormal motion
-abnormal position
--scapular winging
-decreased stability
often diagnosed secondary to another pathology
```
27
scapular dyskinesis
| -clinical presentation
clinical presentation
- tenderness
- -coracoid, pec minor, superior and medial scap borders, AC joint, posterior GH joint line, subacromial space (linked with impingement syndrome)
- muscle spasm
- upper trap
- posterior cervical musculature
- levator scapulae
- static position
- depression
- protraction
- anterior tipping
- ROM
- -GIRD
- -posterior shoulder tightness
- MMT
- -weak middle trap/lower trap
- -weak serratus anterior
- -weak rotator cuff
28
scapular dyskinesis
| -intervention
```
dynamic function assessment
intervention
-associated pathology
-modify activity as needed
-rehabilitation
always address scapular function
```
29
impingement syndrome
| -types
decrease in available space
types
-external (primary and secondary)
-internal
30
external
- primary structures
- onset
- causes
- cycle of dysfunction
```
occurs in subacromial space
primary structures
-rotator cuff tendons
-LHBT
-subacromial bursa
insidious onset
causes
-overuse
-postural insufficiencies
cycle of dysfunction
-rotator cuff is pinched
-as it is impinged it becomes inflamed
-leads to more pinching
```
31
primary external impingement
occurs from change in acromion
types of acromions
-type 1: flat, plenty of space for movement
-type 2: slight curvature off bottom of acromion
-type 3: more of a hook
-type 4: multiple bone spurs (highest risk)
can require surgical intervention to shave down the acromion
32
secondary external impingement
```
modifiable factors
risk factors
-GIRD, rotator cuff weakness, scapular dyskinesis, poor posture, GH instability
S/S
-pain beneath the acromion
-possible radiating pain (lateral arm)
-possible mechanical symptoms
ROM-pain with AROM/PROM, RROM above 90 degrees
-active abduction from 70-120 degrees in painful
--activates the supraspinatus
-intervention
--treat symptoms
--activity modification
--strengthen and stretch
```
33
internal impingement
```
between humeral head and glenoid
most common
-posterosuperior impingement
-infraspinatus and supraspinatus impinged during abduction and ER
sources
-GIRD
-GH instability
-repetition
Tx
-rehabilitation
-scapula control
-posture
```
34
rotator cuff tendinopathy
```
supraspinatus is at most risk
insidious onset
early - pain after activity
progresses to pain during activity
finally pain with ADLs and pain may radiate into lateral arm
contributing factors
-muscular imbalance
-capsular laxity
-poor scapular control
-impingement
Tx
-decrease inflammation and pain
-address scapular stability
-address weakness and motion issues
-surgical intervention for tears
```
35
rotator cuff tears
may result from a single trauma or repetitive trauma
a partial tear may develop into a full-thickness tear if unaddressed
clinical presentation
-lack of control with lowering out of abduction
-significant pain and weakness
36
clavicle fractures
```
MOI
-direct blow to the shoulder
-indirect force
S/S
-pain
-deformity and point tenderness
-crepitus
-inability to raise arm
Tx
-immobilization, referral
-surgery is rare
most common fracture point is approximately 2/3 distally
```
37
humerus fracture
```
most common at surgical neck
-transverse fracture
radial nerve involvement
MOI
-high velocity impact
-FOOSH
S/S
-pain
-deformity
-dysfunction
Tx
-splint
-refer
```
38
SC joint sprains
MOI
-longitudinal force on the clavicle
S/S
-pain with protraction, retraction, and horizontal adduction
-dislocation: displacement of the head of the clavicle
--lost of ligamentous stability
--little bony stability
-pain with GH elevation
-+ SC joint play
--grade 1: pain without laxity
--grade 2 and 3: laxity
posterior dislocations = medical emergency
--trachea, esophagus, subclavian artery and vein
39
AC joint sprains
- MOI
- S/S
```
"separated shoulder"
MOI
-FOOSH
-direct blow to acromion process
S/S
-pain over distal clavicle, AC joint, neck, superior scapula, deptoid
-step deformity
--occurs with grade 2 or higher
--drop off from clavicle down to acromion
-piano key sign
--rise or fall of distal clavicle with palpation/joint play
-pain with GH elevation
```
40
AC joint sprain classifications
| -based on
based on...
- structures involved
- degree of instability
- direction of displacement
41
AC joint sprain type I
damage to joint capsule
| damage to AC ligament
42
AC joint sprain type II
AC ligament rupture
coracoclavicular ligament involvement
slight laxity
potential mild deformity
43
AC joint sprain type III
obvious deformity
AC ligament rupture
coracoclavicular ligament rupture
44
AC joint sprain type IV
rupture of AC and CC ligaments
posterior displacement
possible deltoid and trap involvement
45
AC joint sprain type V
superior displacement of clavicle
| 1-3x the height of the opposite side
46
AC joint sprain type VI
inferior displacement of clavicle
47
AC joint sprain treatment
splint and refer - if laxity
most treated non-surgically
-same outcomes for surgery and non-surgery
pad for RTP
48
glenohumeral instability
- anterior
- MOI
- Tx
laxity of anterior structures
anterior dislocation most common (most severe)
MOI
-abduction and ER
80-90% of young males who dislocate their humerus anteriorly will do it again
Tx
-strengthening
--rotator cuff
-if you have decreased static stability you need more dynamic stability
-surgery
49
injuries secondary to anterior dislocation
```
Bankart lesion
-damage to anterior or inferior labrum
Hill-Sachs lesion
-posterior humeral head
-catches on rim of glenoid and creates a lesion
Fx of glenoid rim
-may occur with Bankart lesion
```
50
posterior instability
| -MOI
uncommon
MOI
-flexion - IR - posterior longitudinal force
--classic carry of a football and fall on elbow
Reverse Hill-Sachs-Lesion
51
inferior instability
greatest when arm elevated over 90 degrees
| arm will appear stuck in an elevated position with inferior dislocation
52
multidirectional instability
any two or more directional instabilities
problem: if you surgically go after one, you make the other worse
Tx
-modify lifting
--don't push weight overhead
53
bicipital tendinopathy
commonly concurrent with rotator cuff pathology/impingement
54
SLAP lesions
```
superior labrum anterior posterior
acute or repetitive trauma
S/S
-anteroposterior shoulder pain
-increased pain at 90 degrees of flexion and 90 degrees of external rotation
-clicking or catching
DDx
-impingement syndrome (clicking and catching)
```
55
SLAP lesion types
| -Tx
Type 1
-fraying of the labrum near the insertion of the LHBT
type 2
-avulsion of the labrum with an associated LHBT tear
OR
-isolated to just the anterior or posterior aspect
type 3
-bucket handle tear of the labrum
type 4
-bucket handle tear of the labrum and tearing of the LHBT
types 3 and 4 are associated with glenohumeral instability
Tx
-based on Sx
56
shoulder examination history
past medical history
- previous history
- AC or GH injury can alter biomechanics
- C-spine pathology
- can radiate pain to upper extremity
57
pain with throwing functional assessment
```
pain in follow-through
-indicative of rotator cuff
pain in cocked position
-anterior instability/impingement (especially internal)
pain in deceleration
-biceps tendon
-SLAP lesion
loss of control and/or velocity
-internal impingement
```
58
shoulder inspection
Sprengel's deformity
-congenitally undescended scapula
rounded forward shoulders typically present with thoracic kyphosis
59
SC joint play
anterior: SC ligament
posterior: SC ligament
inferior: interclavicular ligament
superior: costoclavicular ligament
60
AC joint play
inferior: AC ligament
superior: conoid ligament, trapezoid ligament, AC ligament
anterior: AC ligament, coracoclavicular ligament
posterior: AC ligament, bony block
