Week 13 - Shoulder Flashcards
Shoulder facts?
The shoulder is an extremely complicated complex
- High degree of mobility, but less stability
- Involved in many overhead activities in sport, making it
susceptible to repetitive and overuse injuries
Shoulder Observation?
Site
* Deformity, swelling, discolouration
* Limb positioning
* Elevation or depression of shoulder
tips (inferior angle of the scapula)
* Position and shape of clavicle
* Acromion process (step deformity)
* Biceps and deltoid symmetry
* Scapular elevation and symmetry
* Scapular protraction or winging
* Muscle symmetry
Look from front and back
Shoulder Gait?
Gait
* Asymmetrical arm swing
* Leaning toward painful
shoulder
Scapulohumeral Rhythm
Shoulder Posture?
Posture
* Postural assessment
(kyphosis, lordosis, shoulders)
* Rounded shoulders
* Position of head and arms
* Forward head posture
Shoulder Scapulohumeral Rhythm?
- The scapula stabilizing muscles allow for proper joint motion,
alignment, and stability - Movement of scapula relative to the humerus
- First 30 degrees of glenohumeral abduction: no scapular movement
(setting phase) - Above 30 degrees: scapula abducts and upwardly rotates 1 degree
for every 2 degrees of humeral abduction
Shoulder Palpation?
Be aware of what you are palpating!
* Anatomy learned in lab
* If something hurts, think about what structure you are on
* Bony landmarks will help you localize ligaments and
tendon insertions
* Feeling for: swelling, heat, abnormality, muscle guarding,
trigger points (SHARP)
Glenohumeral Stability Load and shift Test?
Load and shift
* Translation of 1 cm or greater indicates glenohumeral
ligament instability
GHST Anterior and Posterior Drawer tests?
Increased translation/apprehension/pain indicates
anterior/posterior instability
GHST Apprehension Test?
Pain, apprehension indicates shoulder instability
Crank test
GHST Relocation test?
Pain diminishes (positive test)- indicates secondary
impingement (result of poor glenohumeral stability)
- Pain remains (negative test)- indicates primary impingement
(pain not dependent on arthrokinematics)
GHST Release test?
Pain with release (positive test) indicates secondary
impingement
Sulcus Sign Test?
Sulcus sign test
* Dip below acromion (positive
test) unilaterally indicates
inferior glenohumeral instability
Clunk Test?
- Clunk test
- Pain, grinding sound (positive test) indicates labral tear
O’Brian’s Test?
Pain with internal rotation,
diminished with external
rotation indicates SLAP lesion
* Superior labrum anterior
posterior
Yerganson’s Test?
Pain with resisted supination
indicates SLAP lesion, biceps
tendinitis
Clavicular Mobilization?
Clavicular mobilization
* Increased mobility indicates AC joint pathology
Impingement Tests (3)?
Neer’s Test
* Pain indicates subacromical
impingement
-
Hawkins-Kennedy Test
* Pain indicates subacromial
impingement
Empty Can Test
* Pain indicates subacromial
impingement
Drop Arm test?
Drop Arm Test
* Inability/difficulty maintaining
position indicates supraspinatus
tear
Speed’s Test?
Speed’s Test
* Pain in bicipital groove indicates
biceps pathology
Clavicular # MOI and S&S?
MOI = FOOSH
- Most common in the middle third
S&S = Sternocleidomastoid elevates proximal end and shoulder drops at distal end = deformity
Swelling quickly, TOP, ecchymosis
Patient support injured arm
Clavicular # Tx and Prevention?
Immediate Tx:
* Sling/splint, treat for shock
* Call EMS
* Immobilized 6-8wks
* Figure 8 brace
* Sling additional 3-4 weeks
Prevention:
* Properly fitting shoulder pads in contact
sports
* Educate on proper falling mechanics
Humeral # MOI and S&S?
MOI:
* Shaft: direct blow
* Comminuted or transverse
* Proximal humerus: FOOSH,
direct force
* Epiphyseal growth plate: < 10 years of age,
direct/indirect trauma
SSx:
* Pain, possible deformity, inability
to the arm, ecchymosis, swelling,
possible wrist drop and inability
to do supination (radial nerve
involvement)
Humeral # Tx?
Immediate Tx:
Treat for potential shock
* Splint or sling, treat for
shock
* Radiograph to confirm
* Nondisplaced: immobilized
6-8wks in sling
* Displaced: surgery (ORIF)
* Functional recovery in 2-6
months
Risk of developing frozen shoulder during immobilization
Sternoclavicular Sprain (SC) MOI and S&S Grading (1-3)?
- MOI:
- Direct blow, anterior force
- Indirect force along the long axis of the clavicle
SSx:
* Grade I: localized SC pain, TOP, slight disability
Grade II: pain, joint displacement, swelling, point
tenderness, decreased ROM (shoulder abduction, horizontal adduction)
* Partial tear of SC and costoclavicular ligaments
Grade III: gross deformity (dislocation), pain,
swelling, decreased ROM
* Full rupture to both SC, costoclavicular
ligaments
* Possibly life-threatening if dislocates posteriorly
* Difficulty breathing, swallowing, decreased
circulation, voice change
SC sprain Tx and prevention?
Immediate Tx:
* POLICE, sling (Figure 8 brace)
* EMS if posterior grade III sprain
* Immobilize for 3-5 weeks followed by
gradual reconditioning
Prevention:
* Direct blows difficult to prevent
* Proper falling technique
AcromialClavicular Sprains MOI?
“Separated shoulder”
* MOI:
* Direct blow, upward force from
humerus (FOOSH)
AC Sprains G1?
SSx (based on Rockwood
classification)
* Grade I: no disruption of AC joint
* Point tenderness, pain with
shoulder abduction, horizontal
adduction
AC Sprain G2?
Grade II: tear or rupture of AC
ligament, partial displacement of
distal end of clavicle
* Pain, point tenderness,
decreased ROM (abduction,
horizontal adduction)
AC sprain G3?
Grade III: rupture of AC and
coracoclavicular (CC) ligaments
Step Deformity
* Significant superior
displacement of distal clavicle
* Pain, decreased ROM
(abduction, horizontal adduction)
AC Sprain G4?
Grade IV: rupture of AC ligament
* CC ligament may remain intact
* Posterior clavicle displacement
* Pain, decreased ROM
Ac Sprain G5?
Grade V: rupture of AC and CC
ligaments, tearing of deltoid and
trapezius attachments
* Superior and posterior clavicle
displacement
* Gross deformity, severe pain,
decreased ROM
AC sprain G6?
Grade VI: rupture of AC and CC
ligaments, tearing of deltoid and
trapezius attachments
* Inferior displacement of clavicle
behind the coracobrachialis
tendon (rare)
* Gross deformity, severe pain,
decreased ROM
AC Sprain Tx and Prevention?
Immediate Tx:
* POLICE
* Sling, referral to physician
* Grades I-III (non-operative):
* 3-4 days to 2 weeks of
immobilization
* Grades IV-VI: surgery
* Open reduction internal fixation
(ORIF)
Prevention:
* Proper protective shoulder padding
* Proper fall technique
Biceps Brachii Strain MOI + S&S?
MOI:
* Long head of biceps strained with
forceful muscle contraction
* Usually eccentric contraction
during follow through of throwing
SSx:
* Pain/weakness with active
shoulder/elbow flexion and
supination, pain with active/passive
shoulder/elbow extension
* Swelling, ecchymosis
* Grade 3: Snap heard, sudden
intense pain, muscle bulge with
contraction (Popeye sign)
Biceps strain Tx and Prevention?
Immediate Tx:
* POLICE, sling
* Grade 3: Referral to
hospital, possible surgery –> but not very often. Usually just strengthening muscles that do elbow flexion can compensate.
Prevention:
* Flexibility training
* Correct biceps/triceps
imbalances
* Proper warm up
Shoulder Impingement MOI?
MOI:
* Repetitive compression of the
supraspinatus tendon (most common),
long head of the biceps tendon and/or the
subacromial bursa due to decreased
subacromial space
* Usually occurs with overhead activity
* Associated with hypermobility, decreased
capsular stability, weakness of rotator cuff
muscles, poor scapulohumeral rhythm
* Associated with hooked acromion and
forward head posture/rounded shoulders
Shoulder Impingement S&S?
SSx:
* Diffuse pain around acromion whenever
arm is overhead
* Painful arc between 70-120 degrees
abduction
* Affected areas (supraspinatus tendon,
long head of biceps tendon) tender on
palpation
* Pain with side sleeping
* Positive Neer’s, Hawkins-Kennedy
* Positive Empty Can Test, Drop Arm Test
(if supraspinatus tear)
* Possible weakness of rotator cuff
Shoulder Impingement S&S for Neer’s Classification Stage 1?
Occurs in patients <25 years old
* Initial injury to supraspinatus or long
head of biceps
* Aching after activity, point tenderness
over tendons
* Pain during abduction (worse after 90
degrees), straight arm shoulder flexion,
resisted supination with external rotation
* Inflammation
* Temporary thickening of rotator cuff and
subacromial bursa
* Possible atrophy and constriction of
shoulder muscles
Chronic Injuries
Shoulder Impingement S&S for Neer’s Classification Stage 2?
Stage II:
* Permanent thickening and fibrosis
of the supraspinatus and biceps
tendon and possibly subacromial
bursa
* Aching during activity (worse at
night)
* Decreased ROM
Shoulder Impingement S&S for Neer’s Classification Stage 3?
Stage III:
* Patients 25 – 40 years old
* Hx of shoulder problems
* Shoulder pain during activity,
increased pain at night
* Tendon defect < 1 cm
* Possible partial muscle tear
* Permanent thickening of rotator
cuff and acromial bursa with scar
tissue
Shoulder Impingement S&S for Neer’s Classification Stage 4?
Stage IV:
* Patients > 40 years old
* Infraspinatus and supraspinatus
wasting
* Pain with abduction to 90 degrees
* Tendon defect > 1 cm
* Limited AROM, full PROM
* Weakness with abduction and
external rotation
* Possible degeneration of clavicle
Shoulder Impingement Tx for Grades 1/2?
Tx (grades I and II):
* POLICE, avoid aggravating
motions (overhead)
* Strengthen rotator cuff/scapular
stabilizers
* Increase neck flexibility, stretch
pecs (correct posture/increase
subacromial space)
* Joint mobilization, myofascial
release of scar tissue
* Functional recovery in 2-6
weeks
Shoulder Impingement Tx for Grades 3-4?
Tx (grades III and IV):
* Immobilization and complete
rest
* Possible surgery (subacromial
decompression) - acromiaplasty
Bicipital Tenosynovitis/ Tendonistis - MOI and S&S?
MOI:
* Overhead activities that cause ballistic stretching or
repetitive overloading causes rubbing of the tendon on
the transverse humeral ligament and traction at tendon
attachment site
SSx:
* Bicipital groove TOP, swelling, warmth, possible
crepitus, pain in anterior shoulder when throwing,
subluxation of tendon may occur
* Positive Yergensen’s, O’Brien’s, Neer’s, Hawkins-
Kennedy, Speed’s tests
Bicipital Tenosynovitis/ Tendinistis Tx and Prevention?
Immediate Tx:
* POLICE
* Load management
* Avoid aggravating activities
* Gradual program of strengthening and stretching biceps
* ECCENTRICS
* Functional recovery in 6-8 weeks
Prevention:
* Strengthening biceps (eccentrics)
* Proper training intensity progression
* Strengthen rotator cuff and postural muscles
Adhesive Capsulitis MOI?
MOI:
* Usually with older patients
(no known cause) or
following a shoulder injury
that is not properly treated
and rehabilitated
* Immobilization or decreased
movement for an extended
period results in a contracted
and thickened joint capsule
* Rotator cuff muscles
contracted and inelastic
Adhesive Capsulitis S&S?
SSx:
* Pain and reduced ROM in all movements (especially
flexion and external rotation)
* Phase 1: increased pain and inflammation
* Phase 2: pain, ROM limited by stiffness
* Phase 3: reduced pain, but ROM severely limited due
to stiffness
Adhesive Capsulitis Tx and Prevention?
Immediate Tx:
* Phase 1: ROM in painfree range
* Phase 2: Heat, ROM and
stretching
* Phase 3: Heat, aggressive
stretching and joint mobilizations
* Functional recovery 6-24 months
AVG = 1 year
Prevention:
* Avoid prolonged immobilization
