Week 2: Shoulder Instability Flashcards
1
Q
How many people does shoulder instability affect?
A
- As high as 2% of the population
- 3x more common in men than women
- Underestimate the true numbers, only include episodes of dislocation
2
Q
What enhances shoulder stability?
A
- Labrum (bony congruency)
- Negative pressure in GH joint
- Muscle and tendons
- Ligaments and capsule
3
Q
Differentiate b/t laxity and stability
A
-
4
Q
Instability classifications
A
- Traumatic
- Atraumatic
- Acquired
5
Q
What is subluxation?
A
-
6
Q
What is dislocation?
A
-
7
Q
Bankart lesion
A
Tear of the glenoid labrum in anterior region of glenoid
8
Q
Reverse Bankart lesion
A
Tear of the glenoid labrum in posterior region of the glenoid
9
Q
Hill-Sachs lesion
A
Compression fracture of the humeral head occurring as result of traumatic dislocation anteriorly
10
Q
Reverse Hill-Sachs lesion
A
Compression fracture of the humeral head occurring as result of traumatic dislocation posteriorly
11
Q
What part of the humerus is affected in a Hill-Sachs lesion?
A
Posterolateral humerus
12
Q
What part of the humerus is affected in a reverse Hill-Sachs lesion?
A
Anteromedial humerus
13
Q
What direction of instability is most common?
A
- Anterior
- 90-95%
14
Q
What are the characteristics of anterior instability?
A
- Unidirectional w/ traumatic onset
- ABD and ER
- May have a Bankart lesion w/ it
15
Q
How common is posterior instability?
A
2-10%
16
Q
What are the characteristics of posterior instability?
A
- Unidirectional w/ repetitive loading
- ADD and IR
- May have a reverse Bankart lesion w/ it
17
Q
How common is multidirectional instability?
A
1-3%
18
Q
What are the characteristics of multidirectional instability?
A
- Atraumatic
- Congenital or acquired laxity
19
Q
Biceps tendon/SLAP lesions
A
May or may not be associated w/ GH instability
20
Q
What kind of traumatic MOI occurs with anterior dislocation?
A
- Combo of abduction, extension, and posteriorly directed force on arm
- Fall on an outstretched hand is common MOI for elderly
21
Q
MOI for atraumatic injury to shoulder
A
- Anatomical anomaly
- General laxity
- Poor muscle balance
- Scapular dyskinesis
- Connective tissue diseases
22
Q
Scapular dyskinesis
A
-
23
Q
Connective tissue diseases of the shoulder
A
- Ehlers-Danlos Syndrome
- Marfan Syndrome
24
Q
Ehlers-Danlos Syndrome
A
-
25
Marfan Syndrome
-
26
MOI for acquired instability
- Gradual development of laxity
- Excessive ER
- Posterior GH joint capsular tightness
- Strength imbalance
27
Clinical presentation for traumatic injury
- Pain generalized to shoulder, but localize to the involved tissues
- Apprehensive to moving arm out from body
28
What factors does traumatic injury presentation depend on?
- Etiology
- Direction of instability
- Severity
- Frequency
29
Clinical presentation for atraumatic injury
- General multi-joint hypermobility
- Loose inferior capsule
- Atrophy of shoulder girdle
- Dysfunctional movement patterns
30
Clinical presentation for acquired instability
Combo of traumatic and atraumatic
31
General principles to examine for instability
- Observation
- Pain/palpation
- Movement
- Strength
- Sensation/proprioception
32
Observation for examination of instability
- "Protective" posture
| - Presence of observable deformities, muscle atrophy
33
Pain/palpation for examination of instability
Diffuse pain over anterior and posterior shoulder
34
Movement for examination of instability
Unable/unwilling to move into end ranges
35
Strength for examination of instability
- Limited by pain, weak ABD and ER
- Ability to co-activate dynamic stabilizers likely diminished
- Check rotator cuff and scapular muscles
36
Sensation/proprioception for examination of instability
- Conduct sensory screen of shoulder complex
| - Proprioception deficits may be noticeable
37
Test item cluster for anterior instability
- Apprehension test
- Relocation test
- Surprise test
- Sp = 1.00
38
Apprehension test
-
39
Relocation test
-
40
Surprise test
-
41
Anterior drawer test for shoulder instability
-
42
Special test for posterior instability
Jerk test
43
Jerk test
-
44
Special test for labral tear
- Kim test
| - Biceps load test II
45
Kim test
-
46
Biceps load test II
-
47
Risks for recurring dislocations
- Age-related
- Gender
- Fractures
48
Age-related risks for recurring dislocations
- 20s have 60% rate of recurrence
| - 30s have 20% rate of recurrents
49
Gender-related risks for recurring dislocations
- 47% recurrence for men
| - 27% recurrence for women
50
Fractures and risks for recurring dislocations
Reduced risk of recurrence w/:
- Boney Bankart
- Greater tubercle fracture
51
Key Factors for Consideration with Rehab of an unstable shoulder
- Onset of instability
- Degree of instability (subluxation vs dislocation)
- Frequency of episodes
- Direction of instability
- Concomitant abnormalities/injuries
- End-range neuromuscular control
- Pre-morbid activity level
52
Phases of non-operative management of anterior instability
- Phase 1- Acute phase
- Phase 2- Intermediate phase
- Phase 3- Advanced strengthening
- Phase 4- Return to activity
53
Phase 1- Acute phase goals for non-operative management of anterior instability
- Diminish pain, inflammation, and muscle guarding
- Promote and protect healing soft tissues
- Prevent negative effects of immobilization
- Reestablish baseline dynamic joint stability
- Prevent further damage to GH joint capsule
54
Phase 1- Acute phase interventions for non-operative management of anterior instability
- Immobilization
- PROM- early motion in a protected range
- Strengthening: submaximal, pain free isometrics
- Dynamic stabilization
55
Dynamic stabilization for acute phase
- IR/ER in scapular plane
- Flexion at 100 degrees, 10 degrees horizontal ADD
- Closed kinetic chain
- Scapular re-training
56
Criteria to enter the intermediate phase of non-operative management
Reduced pain and improved motor control
57
Goal of the intermediate phase of non-operative management
Reestablish muscle balance and restore full AROM
58
Interventions for the intermediate phase of non-operative management
- PROM and AAROM to patient tolerance
- IR/ER at 90 degrees of ABD
- Strength/stabilization in mid-range
59
Criteria for entering the advanced strengthening phase of non-operative management
- Minimal pain
- Full ROM
- Symmetric capsular mobility
- Good strength (4.5 MMT)
- Strength, endurance, and dynamic stability of the scapulothoracic and UE regions
60
Focus of the advanced strengthening phase of non-operative management
- Strength and dynamic stabilization at end range
| - Return to full daily activities (not sport)
61
Interventions for the advanced strengthening phase of non-operative management
- Low and high repetition exercises (20-30 reps)
- Co-contraction and dynamic stabilization
- Low intensity plyometric exercise for return to sport
62
Focus of the return to activity phase of non-operative management
Perform a strength program, dynamic stability, and NM control
63
Goal of the return to activity phase of non-operative management
Maintain full, functional, and pain-free ROM
64
Interventions of the return to activity phase of non-operative management
Sport specific activities w/ plyometrics, PNF, and isotonic strengthening
