Pathology of shoulder complex MSK Quiz 3
RC tears: Nonoperative Management include
Immobilization may be needed to promote healing Management of pain and swelling NSAIDs, analgesics, ice packs, electrical stimulation, or other physical agents such as ultrasound Prefunctional phase Return to function phase Throughout each phase of recovery, various tissues can be stretched or torn
ER resistance test
Impingement
Adhesive Capsulitis / Freezing phase
In the early stages of this disabling condition, pain occurs both at rest and during activity
Postoperative Period
Initial postoperative care begins with a period of immobilization Medications for pain and swelling may be prescribed by the physician. Ice packs are applied to the shoulder for 20 minutes, three to five times daily. Patient can actively perform finger, hand, wrist, and elbow mobility exercises. Progressive motion and strengthening exercises Return to function phase
Shoulder pain in post-CVA patients is usually due to what?
Internal rotation contracture rather than the dislocation itself.
Internal Impingement
Involves structures within the glenohumeral joint, over head throwing activities. The humerus is abducted and internally rotated
Primary shoulder impingement
- compressive Intrinsic and extrinsic forces- now thought more due to intrinsic verses actual compression THINK BLOCKED
Overhand throwers such as baseball pitchers, water polo players, and javelin throwers are susceptible to
internal impingement, which occurs when he underside of the rotator cuff hits against the posterior superior glenoid labrum
IR resistance test
intra-articular Tear or impingement
Compression Rotation Test
labral tears
crank test
labral tears
Subacromial Rotator Cuff Impingement Classification Stage I
less than 25 y/o: localized inflammation, edema and minimal cuff trauma
What is the Hallmark sigh for adhesive capsulitis?
limited passive ER of 50% or Less than 30 degrees with arm at side Normal is 90
Primary frozen shoulder
not associated with a systemic condition or history of injury
Subacromial Rotator Cuff Impingement Classification Stage III
over 40 y/o: end-stage usually a tear associated
Bicipital tendonitis is inflammation of the LONG or SHORT head of the biceps due to ?
LONG repetitive overhead activities.
Speed's test
Long head of biceps Impingent SLAP lesions
The lack of external rotation causes
pain
Grade III AC sprains are severe and include the following
May include surgical intervention Equal long term results seen in surgical verse non-surgical intervention Open surgical repair, closed reduction immobilization, and progressive rehabilitation Initial course of treatment in physical therapy is to minimize pain and swelling Continuously reinforce compliance using the immobilizer Minimize downward displacement of UE(no carrying heavy purses) Use upper trap muscles!
Are clavicle fractures more common and primarily in men or women?
Men, under 25 years of age
Glenohumeral Joint ANTERIOR instability AND dislocation are more frequent or infrequent?
More frequent 90%: due to nature of osteology: 18-25y/o sporting activities
Is isolating shoulder function in the main planes of the body (flexion/extension, abduction/adduction, etc) appropriate?
NO
This ? test is examining the patient for ?
Neer, External Subacromial Impingement
Appropriate strategies for shoulder rehabilitation include
Obtain stable scapular platform as soon as possible Rehab the shoulder according to the stage of irritability Shorten the lever arm to decrease load
Proximal Humerus Fractures More complex fractures require what time of intervention?
Open reduction and internal fixation (ORIF) with screws and a plate, as well as prolonged periods of immobilization
Internal impingement becomes an injury when?
Over time, microtrauma from repetitive throwing results in damage to the rotator cuff (SLAP)
Which of the following interventions occur in the immediate postop (pre-functional phase of rehabilitation after a subacrominal decompression?
Pain control Ice packs Ultrasound Manual ROM exercises
Nonoperative Treatment of Impingement and Symptomatic Rotator Cuff Tears include 3 phases of rehabilitation
Phase I - prefunctional Phase II - return to function Phase III - return to activity
Hornblower's Sign
Positive if patient can not abduct due to pain - teres minor
AC joint therapy
Prefunction phase normally lasts 4 to 6 weeks Return to function closely follows the patient's level of motion and strength.
Total Shoulder Arthroplasty
Prosthetic replacement of the humeral head and glenoid cavity.
Internal Impingement, occurs to everyone during .
THROWING Therefore internal impingement in itself is NOT an injury.
Anterior Drawer Test
positive if there is instability/abnormal laxity
Yocum test
subacromial impingement Raise elbow without raising shoulder - test is positive if there is pain
Lift off test
subscapularis weakness/tear/pain
How are AC sprains I,II, III treated?
tconservatively with immobilization, meds, ROM and strengthening. Surgery needed for individuals who require repetitive lifting above shoulder level
Proximal Humerus Fractures Nondisplaced one-part fractures treatment
the affected arm is placed in an immobilizer
Adhesive Capsulitis (Frozen Shoulder)
inflammation of the capsule with fibrotic thickening of anterior capsule Primary: no known cause: DM Secondary: due underlying condition
Infraspinatus ER: lower-intensity strengthening exercise 40% max strength
to optimize activation from the rotator cuff and to de-emphasize input from deltoid In other words, low load to get infraspinatus to load
Most common scapular fractures occur
to the glenoid neck Treatment depends on whether or not there is associated glenohumeral instability
Which 4 muscles create the rotator cuff?
Supraspinatus Infraspinatus Teres minor Subscapularis
Proximal Humerus Fractures Nondisplaced one-part fractures are the most common type? Correct or incorrect treatment
Correct
The shoulder is made up of three main components
1. Osteology (bone) 2. Arthrology (joints) 3. Passive stabilizers: the labrum, superior glenohumeral ligament, middle glenohumeral ligament, inferior glenohumeral ligament and capsule
RSA: Reverse Total Shoulder requires strengthening at 12 or 6 weeks?
12 weeks ( 6 weeks for TSA)
How many muscles attach to the scapula
17
Subacromial Rotator Cuff Impingement Classification Stage II
25-40 y/o : progressive deterioration of the cuff
During normal shoulder abduction or flexion what is the natural ratio between the GH and scapulothoracic joint? Scapulohumeral Rhythm
2:1 ratio of GHJ to scapular movement
What are the movements and degrees in the 1st phase of GHJ? Scapulohumeral Rhythm
30 degrees abduction 60 degrees of flexion
RC tears: Nonoperative Management Period of protection lasting for up to
4 to 6 weeks
Positions: Resting (Joint space largest, soft tissues of ligaments and capsule on slack/OPEN PACK
55-70° abduction 30° horizontal adduction 60° elbow flexion 30° elevation of the forearm from horizontal plane
What is the ER/IR ratio typically in a normal healthy individual?
66%
Hill-Sachs lesion
A compression or "impaction fracture" of the POSTEROLATERAL aspect of the humeral head as a result of anterior shoulder instability
Empty Can (Jobe) Test - 30 degrees in scaption plane
External supraspinatus impingement
Patients over 60 usually will have a tear on MRI, usually asymptomatic or symptomatic?
Asymptomic
What is the most common rotator cuff tears?
Supraspinatus possible DROP ARM
Proximal Humerus Fractures - Complications
Avascular necrosis (AVN) An older population of patients with advancing osteoporosis who have four-part proximal humerus fracture
Horizontal adduction test
AC joint dysfunction Subacromial impingement Pinching
The pain associated with what type of sprain is typically reproduced with shoulder abduction to 90 degrees (the close packed position for the AC joint) and passive horizontal adduction of the glenohumeral joint?
AC joint sprain
GH joint instability and dislocation frequently occur after indirect trauma with the arm
Abducted Elevated Eternally rotated
AC sprain Grade I
Acromioclavicular ligaments STRETCHED but not torn. Coracoclavicular ligaments intact Minimal loss of function
AC sprain Grade II
Acromioclavicular ligaments ruptured/TORN and joint SEPARATED Coracoclavicular ligaments intact Moderate pain and some dysfunction
Instability- What is the predominant pattern of a shoulder with spasticity?
Adduction Internal rotation
A decrease in shoulder ROM, pain, inflammation, fibrous synovial adhesions, and reduction of the joint cavity characterizes
Adhesive capsulitis
What diagnosis is characterized by a decrease in shoulder ROM, pain, inflammation, fibrous synovial adhesions, and reduction of the joint cavity?
Adhesive capsulitis
Bankart lesion
An avulsion of the capsule and glenoid labrum off of the ANTERIOR rim of the glenoid resulting from traumatic ANTERIOR dislocation of the shoulder
Adhesive Capsulitis /Frozen phase
As the condition progresses, pain gradually subsides and then spontaneously disappears. Severely restricted motion and profound loss of function remain.
Secondary frozen shoulder
Systemic Extrinsic - MI or C/S DDD Intrinsic - Rotator Cuff or bicep tendinopathy
Your patient fell on his outstretched arm and dislocated his shoulder in the usual direction for this injury. In her initial evaluation the PT noted that the patient suffered a ? lesion, where the capsule and glenoid labrum avulsed off the anterior rim of the glenoid, as well as a ? lesion, where the posterior humeral head impacted the glenoid.
Bankart, Hill-Sachs
Yergason Test (Active Supination Against Resistance In This Position)
Biceps tendon & SLAP (Superior Labrum Anterior to Posterior)
Close Packed GH position
Close Packed GH: Full Abd & ER or full Add/Ext/IR (hammerlock)
RC tears: Nonoperative management include open or closed kinetic chain activities?
Closed kinetic chain
AC sprain Grade III
Coracoclavicular and ligaments ruptured/TORN with wide SEPARATION of joint Ligament injury
Are fractures of the scapular body rare or most common?
COMMON 49% to 89% and demonstrate the highest incidence of associated injuries 35% to 98%
Which muscle is the PTA trying to strengthen with this exercise?
Subscapularis
Force Couple - Rotator cuff and deltoid
Supraspinatus Infraspinatus Subscapularis Teres minor
In the PREFUNCTIONAL STAGE following a shoulder dislocation, what signs does a PTA look for in a patient to determine whether or not exercises can be progressed?
Decrease pain Decrease swelling Improved strength
Capsular position
ER > Abd > IR
What will biasing the ratio during shoulder rehabilitation of patients with rotator cuff injury and anterior instability to 75% do?
Enhance the ability of the posterior rotator cuff (external rotators) to provide stabilization.
Adhesive Capsulitis /Thawing phase
Eventually the motion returns ~ 80-90% previous
After a stroke the patient has limitations in shoulder EXTERNAL or INTERNAL rotation?
External
Neer and Hawkins-Kennedy both test for
External Subacromial Impingement
A shoulder that stiffens in the CLASSIC PATTERN for the GH joint will be restricted in
External rotation Abduction Internal rotation
What is the most limited ROM/specific order
External rotation Abduction Internal rotation
Hawkins-Kennedy Test
External subacromial impingement
Proximal Humerus Fractures - Complications PTA role
Following and supervising a comprehensive program of early protected limited ROM submaximal isometrics for the scapular stabilizers rotator cuff, and upper arm muscles providing continued protection for the injured site
Rotator cuff tears are classified as
Full thickness Partial thickness Acute chronic Degenerative Small less 1 cm Medium 1-3 cm Large 3-5 cm Massive greater 5 cm
Surgery patients (Surgical Management and Rehabilitation)
Have less postoperative pain and reduced soft-tissue damage Require a prefunctional phase of rehabilitation that emphasizes protection ROM
Proximal Humerus Fractures Four-part classification
Humeral head Lesser tuberosity Greater tuberosity Humeral shaft
Glenohumeral joint POSTERIOR instability and dislocation are rare or common?
RARE usually only seizures
Anterior capsulolabral reconstruction procedure (Surgical Management and Rehabilitation)
Reattaches the capsule to the glenoid
Total Shoulder Arthroplasty general guidelines
Rehab: 0-3 weeks: allow healing of subscap, initiate PROM, pendulums, elbow AROM, ice precautions: use UE for waist level activities and bring hand to mouth with arm adducted. avoid lifting, carrying, pushing, leaning Cautious to remove ROM exercises when reach more 30 ER and more 130 flexion (those who had instability prior to sx) 3-8 weeks: PROM elevation 120, PROM ER 30, isometrics, strengthening at 6-8 weeks 8-16 weeks: AROM, increase function and strength of scap stabilizers more 16 weeks: work or sport
Clavicle Fractures
Result of direct or indirect trauma. Common and primarily affecting men under 25 years of age Care focused on achieving reduction of the fracture fragments, maintaining the reduction, and minimizing the immobilization of the glenohumeral joint of the affected arm Figure-of-eight bandage to maintain proper alignment of the area Duration of immobilization varies; authorities suggest healing takes 4 to 6 weeks or longer
RSA: Reverse Total Shoulder
Reverse shoulder TSA: indicated in management of massive or irreparable RC tears, prox humerus fx resulting in deficient RC, revision of prior TSA with RC deficiency rehab depends on preop deltoid fx, post op stiffness, quality of fixation sling for 4-6 weeks, avoid extension and adduction of shoulder, avoid ER in abduction those with good deltoid function can use arm for waist level activity for first 6 weeks first 3 weeks: 90 deg forward flexion and 20-30 deg ER Deltoid strength paramount
Force couple: downward rotation of scapula
Rhomboids,Levator scapulae, Pectoralis minor
The pain associated with the an AC joint sprain is typically reproduced with the shoulder abduction to 90 degrees (close packed position for the AC joint) and passive horizontal adduction of the GH joint. Right or Wrong
Right
Drop Arm Test
Rotator Cuff tear - supraspinatus
SLAP stands for what kind of tears?
S uperior L abrum A nterior P osterior
Bicipital tendonitis some involves the labrum aka
SLAP injury Bucket Handle tear to the top of the labrum
Rehabilitation of Primary and Secondary Rotator Cuff Impingement Exercises
Scapular stabilization exercises Modification of activities Local and systemic methods to control pain and swelling Corticosteroid injections Ice, ultrasound, iontophoresis, phonophoresis Stretching and strengthening exercises
Up to 80% of post-CVA patients have shoulder pain related to structural or functional instability which include
Shallow joint with poor natural bony fit combined with muscles that are either floppy or tight Reduced sensation Neglect/Lack of awareness of where arm is Poor positioning and handling
The normal ratio can become grossly imbalanced and fall well below the 66% normal ratio in what population?
Shoulder patients and in overhead athletes
Significant or insignificant use of ER-based training for the patient with shoulder dysfunction?
Significant
For every 2 degrees of glenohumeral abduction the scapula must do what? Scapulohumeral Rhythm
Simultaneously upwardly rotate roughly 1 degree
Bicipital tendonitis can be tested as positive if there is pain with palpation in these 2 tests
Speed's Yeargson's
4 stages of adhesive capsulitis
Stage 1: pre-adhesive, synovitis, mild end range pain, often misdiagnosed as impingement Stage 2: freezing, thickened red synovitis, acute discomfort, painful end ranges, connective tissue changes resulting in loss of ROM Stage 3: frozen, fibrotic, less synovitis, mature adhesions, less pain Stage 4: severe restriction, no synovitis, thawing, painless stiffness
Pure plane abduction puts acromion right over the humeral head which can create
Subacromial Impingement
Painful Arc
Subacromial Impingement supraspinatus or bicep
Surgical Management of Shoulder Impingement and Rotator Cuff Tears
Subacromial decompression (SAD) Acromioplasty Open arthrotomy or an arthroscopic procedure Postoperative rehabilitation Similar to nonoperative Phase I Phase II Phase III
What is the common cause of shoulder pain?
The tendons of the rotator cuff are crowded, buttressed, or compressed under the coracoacromial arch, resulting in mechanical wear, stress, and friction.
What is the primary indication for total shoulder arthroplasty?
UNREMITTING PAIN not functionality
Force couple: upward rotation of scapula
Upper trapezius, Serratus anterior, Lower trapezius
When do AC sprains and dislocations occur?
Usually result from a fall on the acromion/direct force or when a force is transmitted from a fall on an outstretched arm proximally to the AC joint
What are the 4 phases in throwing?
Wind up Cocking Acceleration Deceleration or Follow-through
Shoulder pain in post-CVA patients is usually due to INTERNAL ROTATION CONTRACTURE rather than dislocation itself. Yay or Nah
Yay
Limitations in shoulder external rotation play an important role in shoulder pain after
a stroke: With spasticity, the affected arm rests in a predominant pattern of shoulder adduction and internal rotation Without active or passive ranging of the shoulder, internal rotation contracture of the shoulder ensues, and pain follows The lack external rotation explains the etiology of shoulder
The combination of abduction and external rotation in the cocking phase of throwing causes
an impingement of the underside of the rotator cuff against the posterior (back) superior (top) labrum.
The most common direction for laxity and instability of the shoulder joint is
anterior
The treatment for scapular fractures is conservative if
associated injuries have not occurred, using ice and immobilization with shoulder immobilization for 2 to 3 weeks.
Impingement symptoms are usually made worse with overhead activities; the patient must modify activities of daily living (ADLs) and all other motions
below 80 to 90 degrees elevation
Out of the 4 phases, what phase does internal impingement occur?
cocking
The supraspinatus provides a direct
compression
Scapular Fractures result form
direct and severe trauma
Secondary impingement - scapula thoracic articulation
due to underlying instability
Secondary shoulder impingement
due to underlying laxity of the shoulder THINK INSTABILITY
Towel roll application has been shown to
elevate muscular activity by 10% in infraspinatus compared to no towel.
Surgery patients receive slow and protective
external rotation up to 12 weeks postoperatively to ensure healing of all soft tissue.
Apprehensive test
if patient is apprehensive this indicates dislocation/instability
Relocation test
immediately performed after positive result of apprehension test (anterior dislocation)if symptoms are relieved test is positive, indicating anterior instability
Adhesive Capsulitis
increased incidence with DM and thyroid disease 40-65 years, more females, increased risk for involvement of opposite shoulder 12-18 month self-limited process Primary FS: not associated with a systemic condition or history of injury Secondary FS: systemic, extrinsic (MI or c/s ddd), intrinsic (Rc or biceps tendinopathy)
3rd phase, Scapulohumeral Rhythm
more GHJ again
2nd phase, Scapulohumeral Rhythm
more scapula with 1:1 ratio
Bicipital tendonitis treatment:
reduce symptoms activity management improve mechanics return to activities
Rotator cuff tears can be from
trauma or degenerative
Adhesive Capsulitis Acute phase
treatment is focused on controlling inflammation and symptoms of pain. Main goal is to reduce PAIN Physician-prescribed analgesics, NSAIDs, and intraarticular steroid injections can provide some pain relief. ...Injection f/b 6 weeks of PT...then decide on treatment progression
The shoulder is the MOST mobile of all joints with MULTIPLE planes of motion. True or false
true
