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Upper Limb Physiotherapy (PHTY206) > Shoulder > Flashcards

Flashcards in Shoulder Deck (120):
1

What are the muscles of the rotator cuff?

Supraspinatus
Infraspinatus
Teres Minor
Subscapularis

2

What is the function of Supraspintus?

Abducts the arm

3

What are the attachments of Supraspinatus?

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

4

What is the action of Infrapsinatus?

Externally rotates the arm

5

What are the attachments of Infraspinatus?

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

6

What is the action of Teres Minor?

Extenally rotates arm

7

What are the attachments of Teres Minor?

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

8

What is the first rule postoperatively?

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

9

What are the types of shoulder surgery

Acromioplasty/subacromial decompression

Rotator cuff repair

Shoulder stabilisation

Total shoulder replacement

Reverse totally shoulder replacement

10

How can subacromial decompression surgery be done?

Arthroscopic (usual) or open

11

What is subacromial decompression done for?

To increase space under subacromial arch

12

Indications for subacromial decompression surgery?

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

13

What injuries can occur at the acapulothoracic joint?

Fractures (MVA,MBA,fall,direct blow)

Snapping scapula

14

What is snapping scapula characterised by?

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

15

Causes of snapping scapula

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

16

How can snapping scapula be treated?

Physiotherapy
Injection of bursae
Surgery

17

What is scapula dyskinesis

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

18

What is physiotherapy for snapping scapula?

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

19

Surgery for snapping scapula

Debridement of bursae

20

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

Rare 3% of all fractures and dislocations around shoulder

Majority- anterior
Posterior - potentially life threatening

21

What is serious complication of sterno-clavicular joint sprain?

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

22

What are mechanisms of injury SC joint?

Direct- blow to medial clavicle
Seatbelt injuries

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

23

Signs and symptoms SC joint dislocation

Derformity, local pain and tenderness (arm rolled forward)

SOB, venous congestion in neck (posterior) dislocation

24

What are the degrees of SC dislocation?

First degree
Second degree
Third degree

25

What is a first degree SC dislocation?

Minor tearing SC and CC lig- no true displacement

26

What is a second degree SC dislocation?

Complete tear sc; second degree tear cc lig- subluxation

27

What is a third degree SC dislocation?

True dislocation 3rd degree sprain to sc/cc lig

28

What is early treatment for SC joint dislocation?

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

29

What is later stage treatment for SC joint dislocation?

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

Gentle muscle/massage

30

What are complications of SC joint injuries?

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

31

What is the MOI of clavicle fracture?

Fall onto tip shoulder
Direct contact with opponent

32

Complication fracture middle third of clavicle

Often much overlap - dysfunction

33

Treatment for middle third clavicle

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

34

Distal end clavicle fracture:
How common
Complications
Treatment

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

35

Injuries at AC joint

Sprain/dislocation
Osteolysis distal end clavicle
Osteoarthritis

36

How common is AC joint sprain

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

37

S&S AC joint spraint

Local pain, step deformity, instability, restriction shoulder movement

38

MOI AC joint sprain

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

39

What is a type 1 AC joint sprain

Sprain capsule, 1 degree sprain AC ligament
Local tenderness, no deformity

40

Type 11 AC joint sprain

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

41

Type 111 and V AC joint sprain

Complete tear of cc ligament
Marked step deformity

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

42

What are effects of AC dislocation on scap control?

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

43

What is a SICK scapula?

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

44

Management AC joint sprain acute phase

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

45

Management AC joint sprain (later)

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

46

What is osteolysis distal clavicle?

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

47

What is the MOI for osteolysis of distal clavicle

Overuse eg weight lighters who use excessive weights in bench press

48

S&S osteolysis distal clavicle

Pain, stiffness, swelling distal clavicle, pain with HF
Xray/bone scan- moth eaten appearance

49

Treatment for osteolysis distal clavicle

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

50

X-ray appearance of OA

Sclerosis and osteophytes

51

How should weight lifters bench press?

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

52

What are GHJconditions?

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

53

What does SLAP lesions mean?

Superior Labral anterior to posterior l

54

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

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

55

What mag anterior dislocation of GHJ cause

Bankart lesion

56

MOI slap lesion

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

Treatment slap lesion

Conservative or surgical repair
Address biomechanics of throwing

58

S&S slap lesionina

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

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

Beighton score
Type 1 collagen

60

A symptomatic hyper mobility =

Joint laxity

61

What can happen in GHJ hyper mobility

Excessive translation HOH along glenoid on load and shift test

Able to subluxate/dislocate GHJ/SCJ

Increases wear/tear

62

Symptomatic hypermobility of GHJ=

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

63

Treatment hypermobility GHJ

Neuromuscular control

64

Cause of anterior GHJ instability

Trauma
Overuse
Incorrect technique

65

Symptoms anterior GHJ jnstability

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

Who has posterior instability (atraumatic)

Sports population- swimmers, gymnasts, throwers, teenagers

67

Presentation posterior instability GHJ (atraumatic)

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

Cause inferior/MDI

General hyperelasticity
Repetitive overuse or trauma

69

Presentation inferior/MDI

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

What will inferior translation tension?

Superior capsule and IGHL

71

Treatment GHJ instability - all directions

Pain relief
Heat
Cold
NSAIDs
Soft tissue massage
TP
Electro therapy

72

Treatment GHJ instability - anterior

Strengthening subscap, other rotator cuff muscles

73

Treatment GHJ instability - posterior

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

74

MOI anterior dislocation

Forced abduction and external rotation (stop sign)

75

Comorbid anterior dislocation

Involves damage to capsular structures
May also include Labral, bony, ligamentous and muscular damage

76

How common is anterior GHJ dislocation

90-95% all dislocations

77

Presentation anterior GHJ dislocation

Findings may include deformity
Prominent HOH anteriorly

78

Treatment anterior GHJ dislocation

Depends on age

20 - conservative rehab

79

MOI posterior GHJ dislocation

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

What can cause GHJ capsular restrictions?

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

81

Pattern of GHJ capsular restriction

External rotation more painful and > abdication, internal rotation

82

TreAtment of capsular restrictions

Early pain relief
Joint mobilisations in opposite direction to restriction

83

Cause of adhesive capsulitis

Idiopathic insidious onset

84

Who gets adhesive capsulitis

Females (40-60) > makes (3:1)
Predisposition with diabetes and hyperthyroidism

85

Which side does adhesive capsulitis affect?

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

86

Characteristics adhesive capsulitis

Progressive loss of movement and gradual increase in pain
Loss of active and passive movement- ER> abduction> IR

87

Stages of adhesive capsulitis

Freezing
Frozen
Thawing

88

Describe freezing stage of adhesive capsulitis

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

89

Frozen stage adhesive capsulitis

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

90

Recovery stage of adhesive capsulitis

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

91

Pathology of adhesive capsulitis

Capsule adheres to humeral head and inferior fold sticks together

No intrarticular fluid

92

8 clinical identifiers early stage AC

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

General management adhesive capsulitis

Very common to apply wait and see
Often self limiting - 1.5-2 years but a percentage do not recover

94

Management adhesive capsulitis freezing phase

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

95

Management adhesive capsulitis frozen and thawing phases

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

96

Other treatment approaches for adhesive capsulitis

MUA/distension arthrograohy

97

Nerve injuries/entrapment a around the shoulder

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

98

What is a primary shoulder impingement?

Within structures in the subacromial or subcoracoid space

99

What is secondary impingement?

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

What can be impinged in subacromial space?

Supra spinatus
is
Long head of biceps
Subacromial bursa

101

What can be a sub coracoid impingement?2

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

102

What do subacromial impingements often involve?

Repeated flexion tasks

103

Sub coracoid impingement symptoms

Flexion IR and horizontal flexion
Obriens tear position

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

104

What impinges posteriorly?

IS and TM on posterosuperior border of the glenoid

105

Area of pain posterior impingement

Posterior acronym diffuse deep internal

106

Causes posterior impingement

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

107

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

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

108

How can motor control cause secondary impingement

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

What can cause secondary impingement

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

110

How can repetitive overload cause secondary impingement?

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

111

What are the stages of impingement?

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

112

Stage 1 impingement

Oedema and haemorrhage

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

113

Stage 2 impingement

Compressive disease :

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

114

Stage 3 impingement

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

115

Risk factor RC tears

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

116

What is required for ideal scap movement

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

Action Lower trapezius

Depress scap
Posterior tilt
ER

118

Serratus anterior

Anteriorly translates medial border of scapula
Upward rotatio
Posterior tilt
ER

119

In scapular dyskinesis loss of ability to achieve:

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

120

Not to be missed with shoulder pain

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.