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SCS > Shoulder > Flashcards

Shoulder Flashcards

1
Q

What percentage of long head of biceps attaches to superior labrum?

A

50%. The remaining 50% attaches to supraglenoid tubercle.

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2
Q

How is superior labrum different from inferior labrum?

A

Superior is rather loose and mobile, inferior is more tightly attached.

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3
Q

Labral fibers attached to ligaments?

A

Anterior/superior labral fibers appear to be more attached to middle and inferior glenohumeral ligaments that directly to the glenoid rim itself.

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4
Q

Vascularity and nerves of labrum?

A

Receives vascular supply from peripheral attachment to capsule. Anteriorsuperior has poor blood supply, inferior has significant blood flow.

No mechanoreceptors in the labrum but there are free nerve endings in the labrum, biceps/labrum complex, and connective tissue around labrum.

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5
Q

Types of SLAP Tears

A

Type 1: Frayed and/or degenerative labrum with firm attachment of labrum to glenoid

Type 2: Detachment of superior labrum and biceps from glenoid rim.

Type 3: Bucket handle tear of labrum with intact biceps anchor

Type 4: Bucket handle tear that extends into biceps tendon.

Expanded Criteria:

Type 5: Bankart lesion of anterior capsule that extends into anterior/superior labrum

Type 6: Disruption of biceps tendon anchor with flap tear superior labral anywhere from posterior to anterior point

Type 7: Extension of SLAP lesion anterior to involve the area inferior to middle glenohumeral ligament.

There are type 8-10 as well.

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6
Q

What symptoms do SLAP tears give?

A

Instability may occur but more often they result in symptoms of mechanical pain and dysfunction rather than instability.

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7
Q

Hypothesized mechanism of SLAP tears in throwing athletes?

A
  1. Eccentric activity of biceps during arm deceleration
  2. Peel Back Mechanism: When arm in maximum ER/abd the rotation produces twist at base of biceps, transmitting torsional force to the anchor.
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8
Q

Internal impingement

A

Impingement of the Infraspinatus on the posterior/superior glenoid rim in the OH athlete.

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9
Q

Bankart Lesion

A

Injuries to anteroinferior glenoid labrum and often associated with Hill Sachs Lesion.

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10
Q

Hill Sachs Lesion

A

Osseous defect or “dent” in posterior-superior-lateral humerus that occurs from anterior instability or dislocation.

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11
Q

Likely difference in pain presentation for RTC vs Labrum

A

Labrum is usually only painful during movement, versus RTC, which is often painful while at rest.

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12
Q

Likely clinical exam findings with a SLAP lesion.

A
  1. Pain with passive ER at 90 shoulder abduction
  2. Pain during active arm elevation
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13
Q

Special tests for SLAP tears

A
  1. Active compression test
    - 90 flex, 30 H.ADD. Resist flex and there is more pain when doing this in IR vs ER
  2. Biceps load test
    - 90 abd, max ER, full supination. Resist elbow flexion.
  3. Biceps load test 2
    - Same as test 1 but 120 abd
  4. Pain provocation test
    - Passive abd to 90-100, passively ER, more pain with full pronation versus supination
  5. Resisted supination and ER test
    - Shoulder at 90 ab, 65-70 elbow flex, shoulder ER, neutral forearm. Resist maximal supination effort.
  6. Pronated load test
    - 90 abd, full ER, full pronation. Resist elbow flexion.
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14
Q

What types of SLAP tears don’t usually respond to conservative Rx?

A

Type 2 and type 4.

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15
Q

Outcomes for SLAP lesion repairs?

A

Outcomes for Type 2 and Type 4 lesions are good with satisfactory results in over 80% of patients.

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16
Q

Rehab exercises to avoid with SLAP lesions?

A

For compressive injury (FOOSH) WB exercises should be avoided to avoid compression/sheer to superior labrum.

Traction injuries should avoid heavy resisted or excessive eccentric bicep contractions

Peel back should avoid excessive shoulder ER while healing.

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17
Q

Post-Op Rehab For SLAP Depridement?

A
  • Sling for 3-4 days
  • AAROM/PROM immediately after surgery (full by 10-14 days)
  • ER/IR in scapular plane and advance to 90 abd by day 5-7
  • Submaximal, pain-free isometrics for first 7 days
  • Isotonics at start of 2nd week (minus biceps which starts after 2 weeks)
  • Controlled weight training by weeks 4 and 6 (avoid excessive shoulder ext and h abd)
  • Plyometrics by week 6-8
  • Return to sport between weeks 7-10
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18
Q

Isokinetic Strength Ratios

A

ER/IR ratio of 66-76%
ER peak torque/body weight of 18-23%

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19
Q

Rehab for SLAP Repair

A
  1. Sling
    - For 4 weeks (including sleep)
  2. Flexion
    - Week 2: 60; Week 3: 75; Week 4: 90; Week 5-6: up to 145; Week 7-9: 180
  3. ER
    - Week 2: 10-15 (scapular plane); Week 3-4: 25-30 (scapular plane); Week 5-6: 45-50 (45 abd); Week 7-9: 90-95 (90 abd); Week 10-12: 110-115 (90 abd)
  4. IR
    - Week 2: 45 (scapular plane); Week 3-4: 55-60 (scapular plane); Week 5-6: 55-60 (45 abd); week 7-9: 70-75 (90 abd)
  5. Muscle Activation
    - Isometrics immediately (ER/IR, flex/ext)
    - No resisted biceps for 8 weeks and aggressively until 12 weeks
    - 4 weeks: ER/IR isotonics
    - 6 weeks: lateral raises, full can, prone row, T’s
    - 7-8 weeks: throwers 10
    - No WB until 8 weeks to avoid compression/shear
    - Advanced strengthening 10-12 weeks

Criteria For Progression to #6: full, pain-free AROM; good stability; 4/5 strength; no pain/tenderness

  1. Return to Sports
    - Initiate progressive interval sports program 12- 16 weeks
    - Return to play at 9-12 months
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20
Q

Good Exercises / High EMG For Following:
1. Supraspinatus
2. Infraspinatus / Teres Minor
3. Subscap
4. Serratus Anterior
5. Mid Trap
6. Lower Trap

A
  1. Supraspinatus
    - Full can (high supraspinatus EMG but also high mid delt)
    - Prone Full Can (high supraspinatus activity but low mid-delt)
  2. Infraspinatus
    - SL ER (low capsular strain)
    - Prone ER at 90 (more capsular strain)
  3. Subscap
    - IR with arm by side
  4. Serratus Anterior
    - Wall slide
    - Push up plus (less UT activation)
  5. Mid Trap
    - Prone row (all trap active)
    - T c ER (LT as well)
  6. Lower Trap
    - Prone full can
    - T c ER
    - Prone ER at 90
    - Bilateral ER in neutral (ideal UT/LT ratio)
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21
Q

Brace types for Clavicular Fracture

A
  1. Figure of 8
  2. Sling
  3. Immobilizer
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22
Q

Types of AC Sprains

A
  1. Incomplete tear of AC ligaments and joint capsule
  2. Partial tear of coracoclavicular with rupture of AC ligaments/capsule
  3. Rupture AC ligaments/capsule and CC ligaments
  4. Posterior dislocation of clavicle
  5. Severe upward displacement into/through trap
  6. Dislocation inferiorly (locked under coracoid)
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23
Q

Tests For Anterior Shoulder Instability?

A
  1. Fulcrum test
  2. Apprehension test
  3. Load/shift
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24
Q

Tests For Posterior Shoulder Instability?

A
  1. Load / shift
  2. Jerk Test
    - Arm in 90 abd/IR and h add while compressing and assess for clunk
  3. Posterior Drawer
    - Supine, arm in 90 abd and h add to be in line with plane of glenoid. Grab elbow and then use hand near humeral head to do posterior glide
  4. Posterior Apprehension Test
    - Supine arm in 90 flex/IR, apply axial load as stabilizing scapula and assess for apprehension
25
Q

Internal Impingement and What it Can Lead To?

A

Excessive/repetitive contact of greater tuberosity and posterior/superior glenoid rim. Occurs with extreme ER/abd. Can lead to PASTA lesion (partial articular sided supraspinatus tendon avulsion).

26
Q

Special Tests For TOS?

A
  1. Roo’s
    - Arms ER/abd and open/close fists for 3 minutes
  2. Allen’s/Wright’s
    - Palpate radial pulse with arm in abd/ER and head turned away
  3. Adson’s
    - Palpate radial pulse while going into arm ext/abd/ER, then take deep breath and hold while turning head towards that side
27
Q

Vulnerable Phases of Throwing

A
  1. Late Cocking and early acceleration
  2. Deceleration and follow-through
  • Deceleration is most violent phase and has posterior/inferior shear force and maximum RTC contraction
  • Late cocking / early acceleration is anterior shear force at shoulder and valgus stress at elbow
28
Q

ER/IR Strength Ratio

A

65-75%

29
Q

Normal ER For Baseball Players
Normal IR

A

Pitchers: ER 118-141, IR 62
Position: ER 108

30
Q

When is RTC injury most likely to occur with throwing?

A

Deceleration phase. This is when maximal contraction occurs.

31
Q

What percentage of pitchers return to play with RTC repairs?

A

8% of pitchers with full thickness repairs return to prior level of competition. 89% of throwers returned to prior level post-partial thickness repair.

32
Q

Requirements for GIRD?

A
  • Greater than 20 degree loss of IR compared to other side or loss of 10% of total rotation compared to opposite arm
33
Q

Impingement and acromioplasty?

A

Return to play highly unsatisfactory

34
Q

Neuro vascular Conditions of Thrower’s Shoulder

A
  1. TOS
  2. Axillary artery thrombosis
  3. Quadrilateral space syndrome
35
Q

Arm presentation with arterial vs venous TOS

A

Arterial = pale and cold
Venous = swelling and mottled skin

36
Q

What part of brachial plexus is involved during TOS?

A

Lower trunk

37
Q

Quadrilateral space syndrome

A

This space is between teres minor/major and long head triceps/humerus. There is usually tethering of nn/vv bundle in this area (axillary nerve and posterior circumflex humeral artery). Can be aggravated by end range ER/abd.

38
Q

What is the rotator cuff interval?

A

The triangle between the coracoid process, subscapularis tendon, and supraspinatus tendon. The coracohumeral and superior glenohumeral ligament are located here.

39
Q

How should healthy muscles and tendons appear on MRI? Unhealthy?

A

Low signal intensity on all MR sequences for tendons and homogenous intermediate signal for muscle. Tendinopathy increased signal on T2 weighted images.

40
Q

Types of Acromion and Problems

A

Type 1: flat
Type 2: curved
Type 3: anterior hook
Type 4: Convex undersurface

Type 2 and 3 directly correlated with increased incidence of rotator cuff derangement.

41
Q

OA of AC Joint Incidence

A

This is common, especially in patients >40

42
Q

Sn and Sp for RTC and Labral Tears with MRI

A

RTC = 88-100% Sn and Sp for MRI. I enhanced MR is inadequate for capsular or labral problems. MRA increases Sn/Sp to 91-93%.

43
Q

Partial vs Full Thickness vs Complete Tears

A

Partial only goes partially through thickness and full goes all the way through but does not have to extend all the way from anterior to posterior (this is complete tear).

44
Q

What size RTC tears are associated with high retear rate after surgery?

A

> 5 cm and involving at least 2 tendons

45
Q

Meta-Analysis For Surgery vs Conservative Care For RTC Tears?

A

2017 meta-analysis concluded surgery no more effective than conservative Rx for tears. Based on 3 RCT’s for 252 patients.

46
Q

Surgery For Impingement Syndrome?

A

Based on 2008 Cochrane SR. 14 RCT’s of 829 patients. No significant differences in outcomes for subacromial decompression to active non surgical treatment.

47
Q

What movements to GH ligaments check?

A

SGHL = stabilizes in inferior direction and ER
CCHL = Stronger stabilizer than SGHL in inferior direction
MGHL = anterior stability at 45-60 abduction
IGHL = most important stabilizer against anteroinferior dislocation and most taut during throwing.

48
Q

Immobilization after dislocation?

A

Not warranted after primary dislocation. We want to promote safe ROM.

49
Q

Primary versus secondary impingement?

A

Primary impingement is due to mechanical narrowing of the subacromial space and secondary is due to a functional disturbance.

50
Q

Dorsal Scapular Nerve and injury presentation?

A

Innervates the rhomboids and levator scap. Would have trouble retracting the scapula.

51
Q

Types of Stabilizers?

A
  1. Static/passive
  2. Dynamic stabilizers
52
Q

What is a positive hyperabduction test for shoulder instability?

A

Greater that 105 degrees.

53
Q

Best Exercises To Restore LT/MT Activity While Minimizing UT?

A
  1. SL ER
  2. SL Flexion (UT too active in standing)
  3. Prone H ABD c ER (better than H ABD alone)
  4. Prone Extension (standing extension gets upper trap more and better than regular row that gets more UT)
54
Q

Best Exercises For SA > UT Activation?

A
  1. Shoulder scaption above 90
  2. Prone and SL ER
  3. All scapular protraction exercises (including bench press)
55
Q

What does positive sulcus test indicate?

A

Looks at superior GH ligament and generalized GH hyper mobility.

56
Q

Laxity Tests For The Thrower’s Shoulder?

A

Sulcus Test

Apprehension Test

Anterior Drawer Test: Pt supine, abd after to about 90. Forward flex 20 and ER about 30. Stabilize scapula by pushing down on anterior clavicle/coracoid, draw humerus forward with hand that is holding patient’s arm.

Anterior Fulcrum Test: Patient supine, shoulder in 90 abd and full ER. Arm is brought into H ABD ant anterior force to humerus applied. Compare to other side.

Anterior Lachman’s Test: Patient supine, arm in 135 abd and ER. Hold arm with both hands and proximal as well as distal arm translated anteriorly.

Posterior Drawer Test: Similar position to anterior drawer test. Pt supine, shoulder 90, flex forward 20 degrees and flex elbow. Hold elbow with one hand as you grasp humeral head with other and translate backwards.

Posterior Fulcrum Test: Grab elbow with elbow flexed. Shoulder to 90. HADD them while using other hand to apply posterior force to humeral head.

57
Q

Locations of shoulder pain and likely structures?

A
  1. Deep = labrum, underside cuff, minor instability
  2. Lateral Aspect = bursa, supraspinatus tendon
  3. Anterior = biceps tendon
  4. Back of Shoulder = posterior/superior labrum
  5. Top = AC Joint
58
Q

Goals of treating shoulder with swim stroke?

A
  1. Decrease the amount of internal rotation during pull phase
  2. Improve early initiation of ER during recovery phase
  3. Improve tilt angle of scapula

Encourage increased body roll and scapular retraction during recovery phase.

SCS (27 decks)

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