2 degrees of G-H elevation for 1 degree of scapular elevation
Anterior translation of G-H occurs with:
forward elevation above 55 degrees
Posterior translation of the G-H occurs with:
ext > 35 degrees
Strength ratios of the shoulder: IR vs ER
Strength ratios of the shoulder: Add to Abd
Strength ratios of the shoulder: Ext to flex
Which G-H ligament plays an important role to limited ER with the arm at the side and is frequently contracted in shoulders with adhesive capsulitis?
What is the rotator interval?
Space between the subscapularis tendon and the supraspinatus tendon including the coracohumeral ligament and the gleno superior glenohumeral ligament that provides significant amount of stability
What are the four parts of the proximal humerus?
1.) Shaft 2.) Greater tuberosity 3.) lesser tuberosity 4.) head
What are the basic biomechanical functions of the rotator cuff?
Provide stability through force couples and aid in motion about the G-H joint. Depresses the humeral head counteracting the superior pull of the deltoid
Describe the role of the long head of the biceps?
Opinions vary: anterior stability by depressing the humeral head, while also providng strength for elbow flexion, supination, abduction
What is the role of the bicipital groove in anterosuperior shoulder pain?
Differential diagnosis of RTC pathology, AC joint pain, instability, bicep tendons disease. Radiographic degenerative changes helps pin point anterior superior shoulder joint pain to the biceps tendon. These changes include stenosis and osteophyte formation in the groove.
What is the quadrangular space? Which structures pass through it?
Shaft of the humerus, long head of the triceps, teres minor, teres major; the axillary nerve and scapular artery passes through it
What is the triangular space? Which structures pass through it?
Long head of the triceps, teres minor, teres major; the circumflex scapular artery
How is the GHJ stability maintained?
Joint capsule and ligaments which tighten at extremes; RTC and deltoid are dynamic stabilizers function most at mid range
Which structure is the most important static restraint to anterior G-H translation in the 90 degree abducted ER position?
Anterior band of the inferior glenohumeral ligament
What movement does the middle glenohumeral ligament prevent?
anterior translation in the mid range of elevation
What does the superior glenohumeral ligament appear to prevent?
Excessive ER and inferior translation
What is a bankart lesion?
Lesion of the glenoid labrum corresponding to the detachment of the anchoring point of the anterior band of the inferior G-H ligament and middle G-H ligament from the glenoid rim.
What is a HAGL lesion?
represents an uncommon avulsion of the humeral attachment of the glenohumeral ligament
What is a Hill-Sachs lesion and how does it relate to recurrent anterior shoulder instability?
An impression fracture of the posteriorlateral margin of the humeral head caused by impaction on the rim of the glenoid during an anterior shoulder dislocation. Large fractures >30% of the surface contribute to instability
What is the biomechanical function of the clavicle?
A strut between the shoulder girdle and the axial skeleton; improve biomechanical efficiency
Define os acromiale:
unfused acromial epiphysis
What are the three types of acromion:
Type I: flat; Type II downward curve; type III hooked downward
Decribe Neer's classification of rotator cuff pathology:
Stage I: edema and hemorrhage; stage II fibrosis and tendinitis; Stage III bone spur and tendon rupture; stage IV cuff tear arthropathy
What is a partial thickness RTC tear?
With age degeneration or tensile failure of the RTC begins deep within the tissue; can progress to full thickness
Do partial thickness tears heal or progress?
They attempt to heal but most progress to full thickness tears
What is rotator cuff arthorpathy?
Massive tearing , cuff tendon slide off the humeral head causing it to elevate vs depress the humeral head. This causes degeneration.
When are acromioplasty and subacromial decompression required?
Recurrent pain with activity that does not always abate with rest and has failed conservative treatment.
What is primary cuff impairment?
mechanical impingement of the rotator cuff beneath the coracoacromial arch and typically results from subacromial overcrowding
What is secondary cuff impingement?
relative decrease in the subacromial space caused by microinstability of the glenohumeral joint or scapulothoracic instability
What is posterior (internal) impingment?
often seen with overhead athletes where the infra and supraspinatus muscles are pinched between the posterior superior aspect of the glenoid when the upper limb is in the cocked phase (associated with anterior instability)
How is the Neer impingement performed?
Scapular stabilized and arm elevated passively by the elbow to compress the greater tuberosity against the anteroinferior border of the acromion.
Hawkins Kennedy impingement?
Arm at 90 degrees forcibly IR to compress the supraspinatus tendon against the anterior surface of the coracoacromial arch
cross over impingement sign?
Horizontal adduction - superior pain = A/C pathology; anterior pain may be subscap, supraspinatus, and or the long head of the biceps; posterior shoudler pain may be the infraspinatus, teres minor and or posterior joint capsule
Painful arc sign?
painful between 60-120 but lessens towards the end range
Drop arm test:
arm at 90 abd and pt unable to lower arm slowly indicates a tear of the RTC
Lift off sign
hand on back pocket unable to lift off butt - subscap
supraspinatus with IR arm in scaption
arm is at 90 elbow flexion, 90 abd, and ER - infraspinatus
What clinical tests are most predictive of a rotator cuff tear?
supraspinatus weakness, impingement sign, and weakness in ER
Which image study: x-rays, arthography, or ultrasound in diagnosing a rotator cuff tear?
Single contrast arthogram has been considered the gold standard techinque; but ultrasound is very sensitive and specific
Are there radiographic findings associated with symptomatic rotator cuff tears?
Findings such as: greater tuberosity sclerosis, osteophytes, subchondral cysts, and osteolysis were found in RTC tear patients not found in age matched controls
How accurate is MRI for rotator cuff tear?
Arthograph is better than MRI
What is the most common direction and mechanism of injury causing shoulder instability?
Anterior dislocation an indirect force with the arm abducted, extended and ER
What is the most common nerve injury after an ant dislocation of the shoulder?
axillary nerve injury; most commonly presenting as a traction neurapraxia
Describe the most common mechanism for posterior shoudler dislocation?
axial loading of the arm in an adducted, flexed and IR position; blow to the shoulder or FOOSH
Why is post vs ant dislocation more likely after electric shock or convulsive seizures?
Lats, pec major, and subscap overwhelm infraspinatus and teres minor causing post dislocation
What is multidirectional instability with atraumatic onset?
Symptomatic G-H subluxation or dislocation in more than one direction caused by pathological changes: 1.) loose redundant or torn joint capsule 2.) lax ligamentous mech 3.) weakened musculotendious system
For shoulder instability, what is TUBS?
T- traumatic U-unidirectional (anterior) B-bankart lesion (usually present) S-surgery (success rate with nonoperative tx is >20%)
What is meant by AMBRI in describing shoulder instability?
A- atraumatic M- Multidirectional B-bilateral (usually) R- rehabilitation (success >80%) I- inferior capsular shift (procedure if tx fails)
What type of lesion is characterized by the acronym ALPSA?
A- anterior L-labroligamentous P-periosteal S-sleeve A-avulsion; often accompanies ant dislocation and is characterized by the labrum and periosteal sleeve of the anterior glenoid being avulsed and displaced medially
What type of lesion is characterized by the acronym HAGL?
H- humeral A- avulsion G- glenohumeral L- Ligament; occurs after traumatic dislocation in a hyperabducted postion
What is the grading scheme for G-H translatiion?
25% is considered normal, grade I up to 50%; grade II more than 50%; grade III head remains dislocated on release
Clinical tests for posterior instability?
Jerk test: arm flexed to 90 degrees with IR and an axial load is delivered and then adducted and posterior slippage is noted, as it returns to the abducted postion a "jerk" may be noted as the shoulder relocates
Name the tests for shoulder instability:
load shift, sulcus sign, apprehension, relocation, anterior release test
Describe a hills-sachs and reverse hills sachs lesion:
Compression fracture of the posteriorlateral aspect of the humeral head. Results from impact on the anteriorinferior rim of the glenoid during ant dislocation; A reverse hill-sach involes compression of the anteriomedial humeral head with posterior dislocation
What is the suggested view to visualize a hill-sachs?
IR or stryker notch view
What is a bankart lesion, what is its significance
avulsion or detachment of the anterior portion of the inferior glenohumeral ligament complex and glenoid labrum; can cause recurrent instability
Clinical presentation of a posterior dislocation:
ER is limited, may be locked in IR secondary to fx or the lesser tuberosity; may have prominent coracoid and a flattening of the ant aspect of the shoudler
Initial tx for ant shoulder dislocation:
relocate early apply ice and use a sling; quick relocation reduced stretch and compression of neurovascular structure
Following ant dislocation should the shoulder be immobilized in IR or ER:
This topic is controversial: in a study with no immobilization vs immobilization there was no difference in recurrent rates. Immobilization in ER vs IR showed decreased reoccurrence in the ER group, but IR is the more traditional position.
What accounts for a high reoccurrence rate for dislocation:
influenced by age and gender (higher in males and younger individuals) and depends on severity; In a young population if there is a second dislocation there is almost a 100% chance of reoccurrence
Why does the incidence of Rotator Cuff tear increase in pts older than 40 with acute dislocation:
the posterior structures such as the rotator cuff and greater tuberosity complex are weaker.
what nonoperative management is appropriate after anterior shoulder dislocation?
immobilization, a regimen of shoulder rehab should be implemented, positions of abduction and ER should be avoided to prevent excessive stress on the anterior capsule. Eventually progressing to scapular then rotator cuff strengthening; emphasis on ER for teres minor and infraspinatus best exercises with prone ER at 90 abd
define primary and secondary adhesive capsulitis:
Primary: insidiuos; Secondary frozen shoulder after some type of trauma or inciting event
What is the best imaging techniques for adhesive capsulitis
arthogram is the gold standard, and ultrasound is very specific and sensitive
What MRI findings are associated with adhesive capsulitis?
thickening of the coracohumeral ligament, thickening of the joint capsule, or obliteration of the fat triangle between the CHL and coracoid process
Describe the natural resolution of adhesive capsulitis
Freezing: painful stage 2-9 months, diffuse pain with difficulty sleeping on the affected side and restricted movement because of pain; Stiffening (freezing) 4-12 months progressive loss of ROM and decreased function noted; Recovery thawing phase 5-24 months with gradual increases in ROM and decreased pain
Role of PT in tx of adhesive capsulitis
Exercise is more effective than modalities, NSAIDs, and steroid injections; mobilization improves ROM
Do end range mobilization techniques improve ROM with adhesive capsulitis
What has been found to increase glenohumeral abd for mobilizations:
ventral and dorsal glides; small improvements with ER with ant glides
What nonoperative management is appropriate after posterior shoulder dislocation?
Reduction is accomplished with longitudinal traction with the elbow bent accompanies by anterior pressure on the humeral head. Start with pain management, activity modification, and strengthening beginning with scapular then rotator cuff.; avoid pushups and bench press; may immobilize for 2-3 wks in handshake cast
How does translation manipulation differ from long lever manipulation?
translational uses linear forces applied to the humeral head and avoids use of long lever arms that could injure the brachial plexus or shoulder joints
What outcomes are associated with long lever arm manipulation?
It has been shown effective to improve ROM and has a low incidence of the following but still has risk for dislocation, fx, brachial plexus injury, and rotator cuff injury
What outcomes have been associated with translational manipulation under anesthesia
More significant increases in ROM have been reported with this technique.
Describe a typical patient who might undergo total shouler arthroplasty:
age 55-70, but maybe younger with casers of arthritis from previous dislocation or AVN.
Indications for TSA?
OA, OA secondary to trauma from shoulder trauma or surgery, RA, AVN, rotator cuff tear arthorpathy; pain with limitation in motion, radiographic deteriation
Differences in constrained, unconstrained, and reverse TSA
unconstrained most resembles a normal shoulder, constrained takes on the properties of a true ball and socket, and a reverse TSA helps leverage the deltoid for a rotator cuff deficient arm
What is a hemiarthroplasty of the humerus?
It is a resurfacing or replacement of the humeral head.
When is a hemiarthorplasty used over a TSA?
IF the glenoid is intact, if the glenoid lacks enough bone to support a prosthesis, heavy physical demands required after surgery, deficient rotator cuff and OA
Benefit in TSA over hemiarthroplasty?
Hemiarthoplasty best for OA
Describe the Hawkins impingement sign:
Forced IR in the scapular plane
Describe the coracoid impingement test:
Forced IR in the coronal plane
Cross-arm adduction tests for:
Describe the Yocum test:
Active combination of elevation and IR provides info on ability to control superior humeral head translation during active movement
What are the different types of rotator cuff impingement?
Primary, secondary, and internal
Describe the Multidirectional instability sulcus test:
Sitting with arms resting in lap, examiner grasps the distal aspect of the humerus with a rapid traction looking for a visible sulcus sign; tests the superior glenohumeral ligament
Describe A-P G-H testing:
supine with A-P (anteromedial) or P-A (posteriorlateral) transitional in the plane of the G-H joint
Describe P-A G-H testing:
perform at 90 abd
Describe the relocation test:
Identifies anterior instability especially in the overhead throwing athlete; Arm taken to 90-90 while in supine max ER while an anterior-med force applied to the humeral, then the head is relocated with a posterior lateral force; + is reproduction of symptoms with subluxation or reduction of symptoms with relocation; could be instability with secondary or primary impingement or even suggest a SLAP lesion
What is the Beighton hypermobility scale /index:
A series of 9 tests (extremities B'ly) to assess general hypermobility: hyperext of the 5th MCP, passive thumb opposition to forearm, elbow, knee hyperext, standing flexion; + 4/9
What is a Bankart lesion?
Primarily occurs with patients with anterior dislocation with a torn labrum from about 2-6 o'clock on the R 6-10 on the L; anterior inferior detachment of the labrum
What is a SLAP lesion?
Superior labrum anterior to posterior lesion; often has biceps involvement; this can decrease the ability for the G-H to withstand rotational force and increase strain on the ant and inf band of GH ligaments
MOI for a SLAP lesion?
Throwing secondary to tensile failure at the biceps insertion; biceps decelerates the extending elbow during follow through with pitching coupled with the large distraction force present during the violent phase of throwing; secondary theory “peel back mechanism” torsional force with abd and max ER where the biceps peels back the labrum
Describe these general labral tests: Clunk, circumduction test, compression rotation, and crank test
Clunk: circumduction test: arm at 90 ER and cirumducted in to horizontal abd; compression rotation, and crank test: 135 degrees elevation humerus loaded and taken through IR/ER
Describe these SLAP tests:
O'Brien Active compression test: slight horizontal add resisted elevation with IR and then with ER; Mimori test; biceps load and ER supination: arm at 90/90 with resisted supination and elbow flexion;
Functional testing of UE: modified crossover pushup type maneuver
Tape placed 3 feet apart with hands just inside the tape and in a pushup postion; hands are alternating moved as quickly as possible to ea side in a windshield wiper motion; number of touches counted in 15s
Describe primary impingement:
A compressive impingement of the rotator cuff tendons between the humeral head and the overlying anterior third of the acromion, coracoacromial ligament, coracoid, or AC joint; in the subacromial space
Primary signs of impingment:
painful arc, positive neer impingement sign, and ER weakness
Continued impingement can lead to what?
Fibrosis and tendonitis leading to bone spurs and tendon rupture
What are the three types of acromion shapes, which is associated with rotator cuff tears?
Type I: flat; Type II: curved; Type III: hooked (high association with tears)
What is secondary impingement caused by?
Joint instability of the GH
Where is internal/undersurface impingement usually felt?
Ofter with overhead athletes posterior shoulder pain brought on by 90 abd 90 ER can impinge tendons on the post/sup portion of the glenoid lip
What is the purpose of light isometrics with IR/ER in the shoulder?
To increase local blood flow
Why is towel roll placed between the body when doing IR/ER exercises?
It is shown to increase infraspinatus recuitment by 10% and prevents unwanted motions
What effect does an isometric add or abd contraction have on the subacromial space?
It can open / increase the subacromial space, shown at 30, 60, 90, 120, 150 degrees of abd; add was particularly effective
Should low or high intensity exercise be used for the shoulder?
Lower because it will prevent compensation by the deltoid when targeting the rotator cuff
Classification of rotator cuff tears?
What motion can increase tension at the infraspinatus?
IR at 30 and 60 degrees
Are pendulums and pulleys truly passive?
At what week do shoulder surgical patients typically begin strengthening?
Wk 6; when early theoritcal healing is assumed
What are the problems with using empty can to strengthen?
Although it had shown good recruitment of the supraspinatus, it closes off the subacromial space and causes abnormal mechanics at the shoulder blade increasing anterior tilting and IR of the scapula, overall it should poor results when using this method
With any instability surgery what is the number one rehab priority early on?
Protect the healing tissues, therefore ensuring to limit ROM and not put excessive strain on the healing tissues by “stretching” them; physiological ROM should be used
For most instability surgeries by what week is full ROM typically achieved?
With frozen shoulder a contracture of the rotator cuff interval includes what ligaments that can be released to improve ROM?
coracohumeral ligament and superior glenohumeral ligament (which is usually released)
Stretching of the rotator cuff interval is effective in improving what ROM?
What are the four phases of frozen shoulder:
Stage 1: pre adhesive stage – mild end range pain stage 2: freezing stage: very painful end ranges stage 3: frozen: less pain with increased stiffness; Stage 4: thawing – painless stiffness with improving ROM
what is the capsular pattern for the shoulder sometimes seen with adhesive capsulitis?
Limitation of ER > Abd > IR
With the arm at 45 degrees abd what is the primary restraint for abd?
middle G-H lig
With the arm adducted the superior G-H lig restrains what movement?
With the arm abducted fully the inf G-H lig restrains what movement?
In a patient who has “obligate translation” anteriorly following an anterior capsular plication, what direction of mobilization will resolve this situation?
Posterior – translation of the humerus occurs when in a direction opposite the restricted or tightened side from surgery
Excessive ER at the side passive and actively is an indication of compromise of what structure?
Subscapularis; with the arm at the side it restricts ER
To protect the subscapularis s/p anterior total shoulder arthroplasty what is done?
Avoiding IR resistive ex and ER ROM/stretching
With a shoulder HA when does strengthening with resistance begin?
what is the a normal outcome for shoulder ROM s/p TSA ro HA
What would be the likely reason for a patient to achieve 120 degrees passive elevation but only 75 degrees active s/p HA for a 4 part fracture?
Greater tuberosity migration changing the length tension relationship of supra and infrapsinatus