Flashcards in Shoulder Deck (120):
What are the muscles of the rotator cuff?
What is the function of Supraspintus?
Abducts the arm
What are the attachments of Supraspinatus?
O: Supraspinous fossa
I: Superior and Middle of the facet of he greater tuberosity.
What is the action of Infrapsinatus?
Externally rotates the arm
What are the attachments of Infraspinatus?
O: Infraspinatous fossa
I: Posterior facet of the greater tuberosity
What is the action of Teres Minor?
Extenally rotates arm
What are the attachments of Teres Minor?
O: Middle half of the lateral border of the scapula
I: Inferior facet of the greater tuberosity.
What is the first rule postoperatively?
Always follow surgeon's protocol
If not provided- call and ask
If you want to vary, always ask
What are the types of shoulder surgery
Rotator cuff repair
Total shoulder replacement
Reverse totally shoulder replacement
How can subacromial decompression surgery be done?
Arthroscopic (usual) or open
What is subacromial decompression done for?
To increase space under subacromial arch
Indications for subacromial decompression surgery?
Relieve pain from impingement where Conservative measures (physio, corticosteroid injections) have failed
What injuries can occur at the acapulothoracic joint?
Fractures (MVA,MBA,fall,direct blow)
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
Causes of snapping scapula
Muscle strength/length deficits
Poor scapulohumeral rhythm
Infra serratus bursitis
Osteochondroma (benign tumour)
How can snapping scapula be treated?
Injection of bursae
What is scapula dyskinesis
Alteration in normal position or motion of the scapula during coupled scapulohumeral movements
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
Surgery for snapping scapula
Debridement of bursae
How common are sterno-clavicular joint sprain/dislocation and in which direction?
Rare 3% of all fractures and dislocations around shoulder
Posterior - potentially life threatening
What is serious complication of sterno-clavicular joint sprain?
May cause pressure on trachea, oesophagus and/or major vessels
What are mechanisms of injury SC joint?
Direct- blow to medial clavicle
Athlete lying on side - uppermost shoulder compressed and rolled backward
Signs and symptoms SC joint dislocation
Derformity, local pain and tenderness (arm rolled forward)
SOB, venous congestion in neck (posterior) dislocation
What are the degrees of SC dislocation?
What is a first degree SC dislocation?
Minor tearing SC and CC lig- no true displacement
What is a second degree SC dislocation?
Complete tear sc; second degree tear cc lig- subluxation
What is a third degree SC dislocation?
True dislocation 3rd degree sprain to sc/cc lig
What is early treatment for SC joint dislocation?
Gentle joint mobilisations for pain relief
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?
What are complications of SC joint injuries?
Chronic subluxation - damage to intro-articulate disc long term
Discomfort with repetitive/strong upper limb
What is the MOI of clavicle fracture?
Fall onto tip shoulder
Direct contact with opponent
Complication fracture middle third of clavicle
Often much overlap - dysfunction
Treatment for middle third clavicle
Conservative - fig 8 bandage + passive/assisted active ROM to 90 degree flexion
Distal end clavicle fracture:
Involve cc and AC ligaments more prone to nonunion
Injuries at AC joint
Osteolysis distal end clavicle
How common is AC joint sprain
Most frequently injured joint in football, ice hockey, skiing and rugby (12% dislocations)
S&S AC joint spraint
Local pain, step deformity, instability, restriction shoulder movement
MOI AC joint sprain
Fall onto point of shoulder
Direct blow to shoulder
Fall onto outstretched hand
What is a type 1 AC joint sprain
Sprain capsule, 1 degree sprain AC ligament
Local tenderness, no deformity
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
Type 111 and V AC joint sprain
Complete tear of cc ligament
Marked step deformity
Type 1V- posterior displacement clavicle
Type V1 - inferior displacement
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
What is a SICK scapula?
Inferior medial border prominence
Coracoid pain and malposition
Kinesis (movement) abnormalities of the scapula
Management AC joint sprain acute phase
Rest in sling if necessary
Scapular positioning, cervical AROM
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
What is osteolysis distal clavicle?
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
What is the MOI for osteolysis of distal clavicle
Overuse eg weight lighters who use excessive weights in bench press
S&S osteolysis distal clavicle
Pain, stiffness, swelling distal clavicle, pain with HF
Xray/bone scan- moth eaten appearance
Treatment for osteolysis distal clavicle
Rest from activities m, NSAIDs, physiothrrapy (electro, muscle reeducation, trigger point release)
X-ray appearance of OA
Sclerosis and osteophytes
How should weight lifters bench press?
Avoid locking elbows
Narrower grip on bar
Avoid bending their elbows past horizontal
What are GHJconditions?
Hyper mobility syndrome
Dislocation- Labral tear, bankart, hill-Sachs, HAGL lesions
Capsular restrictive process
What does SLAP lesions mean?
Superior Labral anterior to posterior l
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
What mag anterior dislocation of GHJ cause
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
Treatment slap lesion
Conservative or surgical repair
Address biomechanics of throwing
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
What measures generalised hyper mobility syndrome. What tissues does this effect
Type 1 collagen
A symptomatic hyper mobility =
What can happen in GHJ hyper mobility
Excessive translation HOH along glenoid on load and shift test
Able to subluxate/dislocate GHJ/SCJ
Symptomatic hypermobility of GHJ=
Pain provocation on apprehension test:instability/apprehension/feeling weakness
Treatment hypermobility GHJ
Cause of anterior GHJ instability
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
Who has posterior instability (atraumatic)
Sports population- swimmers, gymnasts, throwers, teenagers
Presentation posterior instability GHJ (atraumatic)
Pain- post but also ant due to stretch of structures
Loss normal appearance of front of shoulder
Dumps out the back
Repetitive overuse or trauma
Lax in all directions (May only be symptomatic in one)
Positive: apprehension test, translational tests including sulcus sign
Hypermobility on other side is asymyomatic
What will inferior translation tension?
Superior capsule and IGHL
Treatment GHJ instability - all directions
Soft tissue massage
Treatment GHJ instability - anterior
Strengthening subscap, other rotator cuff muscles
Treatment GHJ instability - posterior
Strengthening posterior deltoid, scapular stabilisers (infraspinatus, teres minor), rotator cuff
Appropriate taping and proprioceptive control
MOI anterior dislocation
Forced abduction and external rotation (stop sign)
Comorbid anterior dislocation
Involves damage to capsular structures
May also include Labral, bony, ligamentous and muscular damage
How common is anterior GHJ dislocation
90-95% all dislocations
Presentation anterior GHJ dislocation
Findings may include deformity
Prominent HOH anteriorly
Treatment anterior GHJ dislocation
Depends on age
20 - conservative rehab
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
What can cause GHJ capsular restrictions?
Post immobilisation and as part of cervical spondylitis flare up
Pattern of GHJ capsular restriction
External rotation more painful and > abdication, internal rotation
TreAtment of capsular restrictions
Early pain relief
Joint mobilisations in opposite direction to restriction
Cause of adhesive capsulitis
Idiopathic insidious onset
Who gets adhesive capsulitis
Females (40-60) > makes (3:1)
Predisposition with diabetes and hyperthyroidism
Which side does adhesive capsulitis affect?
Often unilateral but may occur bilaterally concurrently or in sequence (15%)
Characteristics adhesive capsulitis
Progressive loss of movement and gradual increase in pain
Loss of active and passive movement- ER> abduction> IR
Stages of adhesive capsulitis
Describe freezing stage of adhesive capsulitis
Pain with movement
Generalised ache that is difficult pinpoint
Increasing pain at night and at rest
Frozen stage adhesive capsulitis
Increasing stiffness and restriction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges if movement
Recovery stage of adhesive capsulitis
Marked restriction with slow gradual increase in rom
Recovery is spontaneous but frequently incomplete
Pathology of adhesive capsulitis
Capsule adheres to humeral head and inferior fold sticks together
No intrarticular fluid
8 clinical identifiers early stage AC
-strong component night pain
- pain with rapid unguarded movement
-discomfort lying on affected shoulder/pain easily aggravated
- global loss active and passive rom, pain at end range all directions
-onset greater than 35 years of age
General management adhesive capsulitis
Very common to apply wait and see
Often self limiting - 1.5-2 years but a percentage do not recover
Management adhesive capsulitis freezing phase
Heat , TENS
NO forceful movement
AAROM within limits if pain
Management adhesive capsulitis frozen and thawing phases
EOR joint mobs
Strengthening scapular stabilisers
Other treatment approaches for adhesive capsulitis
Nerve injuries/entrapment a around the shoulder
Supra scapular nerve (burner/stinger syndrome)
Long thoracic nerve
Thoracic outlet syndrome
What is a primary shoulder impingement?
Within structures in the subacromial or subcoracoid space
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
What can be impinged in subacromial space?
Long head of biceps
What can be a sub coracoid impingement?2
Subscap tendon and bursa in the coracohumeral space between lesser tuberosity and coracoid process
What do subacromial impingements often involve?
Repeated flexion tasks
Sub coracoid impingement symptoms
Flexion IR and horizontal flexion
Obriens tear position
Pain anterior portion of shoulder
Painful arc in flexion may be present
What impinges posteriorly?
IS and TM on posterosuperior border of the glenoid
Area of pain posterior impingement
Posterior acronym diffuse deep internal
Causes posterior impingement
Poor neuromuscular control
eccentric overload with ER
Pain reproduction in ER and and
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
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
What can cause secondary impingement
Repetitive overload in sport
Posture and positioning
How can repetitive overload cause secondary impingement?
Fatigue of rotator cuff as centraliser of HOH - loss of control
What are the stages of impingement?
1. Oedema and haemorrhage
2. Compressive disease
3. Bony spurs/tendon ruptures
Stage 1 impingement
Oedema and haemorrhage
From mechanical irritation of tendons in overhead activities
Younger athletic patients
Stage 2 impingement
Compressive disease :
Fibrosis and tendinitis
Repeated episodes mechanical inflammation
Results in thickening or fibrosis subacromial burse
Stage 3 impingement
Bone spurs/tendon ruptures
Continued mechanical compression
Acromial architectures May be involved
Risk factor RC tears
A symptomatic tears progress
Pain highly correlated with progressive/increasing tear size
What is required for ideal scap movement
Trapezius - 3 portions
Need to work in synchrony to elevate, upward rotate and ER scap for ideal glenoid position
Action Lower trapezius
Anteriorly translates medial border of scapula
In scapular dyskinesis loss of ability to achieve:
60 degree upward rotation
ER maintaining medial border flat against rib cage