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Upper Limb Physiotherapy (PHTY206) > Shoulder > Flashcards

Shoulder Flashcards

1
Q

What are the muscles of the rotator cuff?

A

Supraspinatus
Infraspinatus
Teres Minor
Subscapularis

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2
Q

What is the function of Supraspintus?

A

Abducts the arm

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3
Q

What are the attachments of Supraspinatus?

A

O: Supraspinous fossa
I: Superior and Middle of the facet of he greater tuberosity.

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4
Q

What is the action of Infrapsinatus?

A

Externally rotates the arm

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5
Q

What are the attachments of Infraspinatus?

A

O: Infraspinatous fossa
I: Posterior facet of the greater tuberosity

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6
Q

What is the action of Teres Minor?

A

Extenally rotates arm

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7
Q

What are the attachments of Teres Minor?

A

O: Middle half of the lateral border of the scapula
I: Inferior facet of the greater tuberosity.

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8
Q

What is the first rule postoperatively?

A

Always follow surgeon’s protocol
If not provided- call and ask
If you want to vary, always ask

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9
Q

What are the types of shoulder surgery

A

Acromioplasty/subacromial decompression

Rotator cuff repair

Shoulder stabilisation

Total shoulder replacement

Reverse totally shoulder replacement

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10
Q

How can subacromial decompression surgery be done?

A

Arthroscopic (usual) or open

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11
Q

What is subacromial decompression done for?

A

To increase space under subacromial arch

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12
Q

Indications for subacromial decompression surgery?

A

Relieve pain from impingement where Conservative measures (physio, corticosteroid injections) have failed

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13
Q

What injuries can occur at the acapulothoracic joint?

A

Fractures (MVA,MBA,fall,direct blow)

Snapping scapula

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14
Q

What is snapping scapula characterised by?

A

Loud pop/snap or crepitus when scapula cannot move smoothly over rib cage during arm elevation

Infra-serratus bursae can become enlarged, inflamed and fibrotic

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15
Q

Causes of snapping scapula

A 
Scapular dyskinesia
Muscle strength/length deficits
Poor scapulohumeral rhythm
Infra serratus bursitis
Osteochondroma (benign tumour)
Rib/scapular fractures 
Neural paralysis
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16
Q

How can snapping scapula be treated?

A

Physiotherapy
Injection of bursae
Surgery

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17
Q

What is scapula dyskinesis

A

Alteration in normal position or motion of the scapula during coupled scapulohumeral movements

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18
Q

What is physiotherapy for snapping scapula?

A

Check/address lengths of muscles attaching to scapula
Improve muscle strength traps and SA

Correct resting position scapula on thorax
Retrain motor control of scapular movement through range of elevation

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19
Q

Surgery for snapping scapula

A

Debridement of bursae

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20
Q

How common are sterno-clavicular joint sprain/dislocation and in which direction?

A

Rare 3% of all fractures and dislocations around shoulder

Majority- anterior
Posterior - potentially life threatening

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21
Q

What is serious complication of sterno-clavicular joint sprain?

A

May cause pressure on trachea, oesophagus and/or major vessels

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22
Q

What are mechanisms of injury SC joint?

A

Direct- blow to medial clavicle
Seatbelt injuries

Indirect-
Athlete lying on side - uppermost shoulder compressed and rolled backward

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23
Q

Signs and symptoms SC joint dislocation

A

Derformity, local pain and tenderness (arm rolled forward)

SOB, venous congestion in neck (posterior) dislocation

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24
Q

What are the degrees of SC dislocation?

A

First degree
Second degree
Third degree

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25
Q

What is a first degree SC dislocation?

A

Minor tearing SC and CC lig- no true displacement

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26
Q

What is a second degree SC dislocation?

A

Complete tear sc; second degree tear cc lig- subluxation

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27
Q

What is a third degree SC dislocation?

A

True dislocation 3rd degree sprain to sc/cc lig

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28
Q

What is early treatment for SC joint dislocation?

A

Rest/ice/NSAIDs
Gentle joint mobilisations for pain relief
Clavicle strap

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29
Q

What is later stage treatment for SC joint dislocation?

A

Joint mobilisations - A/Ps, MWMs (A/P,P/A/rotation with shoulder elevation)- which direction is the deformity?

Gentle muscle/massage

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30
Q

What are complications of SC joint injuries?

A

Instability
Cosmetic deformity
Recurrent instability
Chronic subluxation - damage to intro-articulate disc long term
Discomfort with repetitive/strong upper limb

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31
Q

What is the MOI of clavicle fracture?

A

Fall onto tip shoulder

Direct contact with opponent

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32
Q

Complication fracture middle third of clavicle

A

Often much overlap - dysfunction

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33
Q

Treatment for middle third clavicle

A

Conservative - fig 8 bandage + passive/assisted active ROM to 90 degree flexion

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34
Q

Distal end clavicle fracture:
How common
Complications
Treatment

A

12-15%
Involve cc and AC ligaments more prone to nonunion
Conservative-sling+AAROM/isometric exc

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35
Q

Injuries at AC joint

A

Sprain/dislocation
Osteolysis distal end clavicle
Osteoarthritis

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36
Q

How common is AC joint sprain

A

Most frequently injured joint in football, ice hockey, skiing and rugby (12% dislocations)

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37
Q

S&S AC joint spraint

A

Local pain, step deformity, instability, restriction shoulder movement

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38
Q

MOI AC joint sprain

A

Fall onto point of shoulder
Direct blow to shoulder
Fall onto outstretched hand

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39
Q

What is a type 1 AC joint sprain

A

Sprain capsule, 1 degree sprain AC ligament

Local tenderness, no deformity

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40
Q

Type 11 AC joint sprain

A

Complete tear AC ligament, partial tear cc ligament
Local tenderness, palpable step deformity
Reduced range of motion into abduction/addiction

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41
Q

Type 111 and V AC joint sprain

A

Complete tear of cc ligament
Marked step deformity

Type 1V- posterior displacement clavicle
Type V1 - inferior displacement

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42
Q

What are effects of AC dislocation on scap control?

A

Chronic type III AC dislocation - scap dyskinesis 70.6% patient
Of latter 58.3%= SICK scapula

Dyskinesis- May be loss of stable fulcrum of shoulder fielder represented by AC joint and due to superior shoulder pain caused by dislocation

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43
Q

What is a SICK scapula?

A

Scapula malposition
Inferior medial border prominence
Coracoid pain and malposition
Kinesis (movement) abnormalities of the scapula

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44
Q

Management AC joint sprain acute phase

A

Ice/taping
Rest in sling if necessary
Isometric exercises
Scapular positioning, cervical AROM

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45
Q

Management AC joint sprain (later)

A

Gentle AROM to limit of pain onset to regain full ROM
mobilisation AC joint - A/P, caudad, MWM
Strengthening of all muscles shoulder girdle
Gradual return to sport

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46
Q

What is osteolysis distal clavicle?

A

Stress fracture
Osteolysis- softening, absorption and dissolution of none or removal/loss kg calcium
Can result in 0.5 to 3 cm of bone loss and AC joint

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47
Q

What is the MOI for osteolysis of distal clavicle

A

Overuse eg weight lighters who use excessive weights in bench press

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48
Q

S&S osteolysis distal clavicle

A

Pain, stiffness, swelling distal clavicle, pain with HF

Xray/bone scan- moth eaten appearance

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49
Q

Treatment for osteolysis distal clavicle

A

Rest from activities m, NSAIDs, physiothrrapy (electro, muscle reeducation, trigger point release)

50
Q

X-ray appearance of OA

A

Sclerosis and osteophytes

51
Q

How should weight lifters bench press?

A

Avoid locking elbows
Narrower grip on bar
Avoid bending their elbows past horizontal

52
Q

What are GHJconditions?

A 
Hyper mobility syndrome
SLAP lesion
Dislocation- Labral tear, bankart, hill-Sachs, HAGL lesions
Capsular restrictive process
Adhesive capsulitis
53
Q

What does SLAP lesions mean?

A

Superior Labral anterior to posterior l

54
Q

What mag cause a slap lesion. What may it occur with

A

Overhead throwing can tear anterosuperior section of labrum with repeated throwing
May occur with acute and chronic overuse injuries

55
Q

What mag anterior dislocation of GHJ cause

A

Bankart lesion

56
Q

MOI slap lesion

A
  1. Abducted/ER position- long head of biceps is vertical and angled posteriorly
    - produces twist at the attachment of biceps tendon and can transmit force through to labrum, causing it to rotate medially and peel off
  2. Follow through phase of throw when eccentric biceps contraction involved with deceleration at release of throw
57
Q

Treatment slap lesion

A

Conservative or surgical repair

Address biomechanics of throwing

58
Q

S&S slap lesionina

A 
Intermittent symptoms, vague ache
May be clicking or catching
May occur in conjunction with other tests
Increased joint laxity
- often secondary to other injuries
-watch post MVAs
59
Q

What measures generalised hyper mobility syndrome. What tissues does this effect

A

Beighton score

Type 1 collagen

60
Q

A symptomatic hyper mobility =

A

Joint laxity

61
Q

What can happen in GHJ hyper mobility

A

Excessive translation HOH along glenoid on load and shift test

Able to subluxate/dislocate GHJ/SCJ

Increases wear/tear

62
Q

Symptomatic hypermobility of GHJ=

A

Pain provocation on apprehension test:instability/apprehension/feeling weakness

63
Q

Treatment hypermobility GHJ

A

Neuromuscular control

64
Q

Cause of anterior GHJ instability

A

Trauma
Overuse
Incorrect technique

65
Q

Symptoms anterior GHJ jnstability

A

Increased translation humeral head-May cause pain

ROM: normal to hypermobile

Apprehension/relocation test positive

PA accessory glide may have increased anterior excursion

Often tenderness posteriorly from tractioning of post structures

66
Q

Who has posterior instability (atraumatic)

A

Sports population- swimmers, gymnasts, throwers, teenagers

67
Q

Presentation posterior instability GHJ (atraumatic)

A

Pain- post but also ant due to stretch of structures
Crepitus/clicking/catching/subluxation/feeling instability
Full/excessive rom
Loss normal appearance of front of shoulder
Dumps out the back

68
Q

Cause inferior/MDI

A

General hyperelasticity

Repetitive overuse or trauma

69
Q

Presentation inferior/MDI

A

Lax in all directions (May only be symptomatic in one)

Positive: apprehension test, translational tests including sulcus sign
Hypermobility on other side is asymyomatic

70
Q

What will inferior translation tension?

A

Superior capsule and IGHL

71
Q

Treatment GHJ instability - all directions

A 
Pain relief
Heat
Cold
NSAIDs
Soft tissue massage
TP
Electro therapy
72
Q

Treatment GHJ instability - anterior

A

Strengthening subscap, other rotator cuff muscles

73
Q

Treatment GHJ instability - posterior

A

Strengthening posterior deltoid, scapular stabilisers (infraspinatus, teres minor), rotator cuff
Appropriate taping and proprioceptive control

74
Q

MOI anterior dislocation

A

Forced abduction and external rotation (stop sign)

75
Q

Comorbid anterior dislocation

A

Involves damage to capsular structures

May also include Labral, bony, ligamentous and muscular damage

76
Q

How common is anterior GHJ dislocation

A

90-95% all dislocations

77
Q

Presentation anterior GHJ dislocation

A

Findings may include deformity

Prominent HOH anteriorly

78
Q

Treatment anterior GHJ dislocation

A

Depends on age

20 - conservative rehab

79
Q

MOI posterior GHJ dislocation

A

Generally sports population
Direct blow to shoulder or fall on outstretched arm with arm position in internal rotation and addiction (fall from bike or horse)

Usually conservative management

80
Q

What can cause GHJ capsular restrictions?

A

Post injury
Inflammation
Post surgery
Post immobilisation and as part of cervical spondylitis flare up

81
Q

Pattern of GHJ capsular restriction

A

External rotation more painful and > abdication, internal rotation

82
Q

TreAtment of capsular restrictions

A

Early pain relief

Joint mobilisations in opposite direction to restriction

83
Q

Cause of adhesive capsulitis

A

Idiopathic insidious onset

84
Q

Who gets adhesive capsulitis

A

Females (40-60) > makes (3:1)

Predisposition with diabetes and hyperthyroidism

85
Q

Which side does adhesive capsulitis affect?

A

Often unilateral but may occur bilaterally concurrently or in sequence (15%)

86
Q

Characteristics adhesive capsulitis

A

Progressive loss of movement and gradual increase in pain

Loss of active and passive movement- ER> abduction> IR

87
Q

Stages of adhesive capsulitis

A

Freezing
Frozen
Thawing

88
Q

Describe freezing stage of adhesive capsulitis

A

Pain with movement
Generalised ache that is difficult pinpoint
Muscle spasm
Increasing pain at night and at rest

89
Q

Frozen stage adhesive capsulitis

A

Less pain
Increasing stiffness and restriction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges if movement

90
Q

Recovery stage of adhesive capsulitis

A

Decreased pain
Marked restriction with slow gradual increase in rom
Recovery is spontaneous but frequently incomplete

91
Q

Pathology of adhesive capsulitis

A

Capsule adheres to humeral head and inferior fold sticks together

No intrarticular fluid

92
Q

8 clinical identifiers early stage AC

A

Pain:

  • strong component night pain
  • pain with rapid unguarded movement
  • discomfort lying on affected shoulder/pain easily aggravated

Movement:

  • global loss active and passive rom, pain at end range all directions
  • onset greater than 35 years of age
  • end range
93
Q

General management adhesive capsulitis

A

Very common to apply wait and see

Often self limiting - 1.5-2 years but a percentage do not recover

94
Q

Management adhesive capsulitis freezing phase

A

Pain relief
Heat , TENS
NO forceful movement
AAROM within limits if pain

95
Q

Management adhesive capsulitis frozen and thawing phases

A 
EOR joint mobs
Mwm
Muscle to
Strengthening scapular stabilisers
RC
posture control
96
Q

Other treatment approaches for adhesive capsulitis

A

MUA/distension arthrograohy

97
Q

Nerve injuries/entrapment a around the shoulder

A

Supra scapular nerve (burner/stinger syndrome)
Long thoracic nerve
Axillary nerve
Thoracic outlet syndrome

98
Q

What is a primary shoulder impingement?

A

Within structures in the subacromial or subcoracoid space

99
Q

What is secondary impingement?

A

External factors reducing size if subacromial space but still affect structures within.

Impingement symptomatic and present but source is something else dysfunctional within the shoulder complex

Joint laxity/restrictions (capsuloligamentous)

Motor control of GHJ Or SC joint
Posture and positions

100
Q

What can be impinged in subacromial space?

A

Supra spinatus
is
Long head of biceps
Subacromial bursa

101
Q

What can be a sub coracoid impingement?2

A

Subscap tendon and bursa in the coracohumeral space between lesser tuberosity and coracoid process

102
Q

What do subacromial impingements often involve?

A

Repeated flexion tasks

103
Q

Sub coracoid impingement symptoms

A

Flexion IR and horizontal flexion
Obriens tear position

Pain anterior portion of shoulder
Painful arc in flexion may be present

104
Q

What impinges posteriorly?

A

IS and TM on posterosuperior border of the glenoid

105
Q

Area of pain posterior impingement

A

Posterior acronym diffuse deep internal

106
Q

Causes posterior impingement

A 
Capsular laxity
Capsular tightness
Poor neuromuscular control
eccentric overload with ER
Pain reproduction in ER and and
107
Q

What can occur with laxity and deficiency in passive restrains to motion of HOH with glenoid increases

A

Lack of HOH control
Excessive translation (anterior posterior or superior inferior)
Impingement can result

108
Q

How can motor control cause secondary impingement

A

Scapular muscle imbalance:

  • anchoring of GHJ muscles and line of force
  • position if glenoid and also HOH
  • -ability of HOH to clear the acromion during function

Rotator cuff weakness:

  • failure to control HOH positions
  • potential increases anterior or superior translation
  • consequence = impingement
109
Q

What can cause secondary impingement

A 
Laxity
Joint restrictions
Motor control 
Repetitive overload in sport
Posture and positioning
110
Q

How can repetitive overload cause secondary impingement?

A

Fatigue of rotator cuff as centraliser of HOH - loss of control

111
Q

What are the stages of impingement?

A
  1. Oedema and haemorrhage
  2. Compressive disease
  3. Bony spurs/tendon ruptures
112
Q

Stage 1 impingement

A

Oedema and haemorrhage

From mechanical irritation of tendons in overhead activities
Younger athletic patients
Reversible

113
Q

Stage 2 impingement

A

Compressive disease :

Fibrosis and tendinitis
Repeated episodes mechanical inflammation
Results in thickening or fibrosis subacromial burse
25-40 yo

114
Q

Stage 3 impingement

A

Bone spurs/tendon ruptures
Continued mechanical compression
Acromial architectures May be involved

115
Q

Risk factor RC tears

A 
Smoking
Hypercholesterolemia
Family history
A symptomatic tears  progress
Pain highly correlated with progressive/increasing tear size
116
Q

What is required for ideal scap movement

A 
Trapezius - 3 portions
SA
Levator scap
Rhomboidal
Pec minor

Need to work in synchrony to elevate, upward rotate and ER scap for ideal glenoid position

117
Q

Action Lower trapezius

A

Depress scap
Posterior tilt
ER

118
Q

Serratus anterior

A

Anteriorly translates medial border of scapula
Upward rotatio
Posterior tilt
ER

119
Q

In scapular dyskinesis loss of ability to achieve:

A

60 degree upward rotation
ER maintaining medial border flat against rib cage
Retraction

120
Q

Not to be missed with shoulder pain

A 
Tumour (bone tumour in the young)
Referred pain:
Diaphragm
Gall bladder
perforated duodenal ulcer
Heart
Spleen (left shoulder pain)
Apex of lungs
Thoracic outlet syndrome
Axillary vein thrombosis.

Upper Limb Physiotherapy (PHTY206) (8 decks)

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