Shoulder Impairments part 1 Flashcards
(43 cards)
4 joints in the shoulder
- Scapulothoracic
- Sternoclavicular
- Acromioclavicular
- Glenohumeral
Scapulothoracic joint
- Not a “true joint” Floats on posterior thoracic wall.
- Only true bony attachment is the acromioclavicular joint
- Protraction, retraction, elevation, depression, upward rotation and downward rotation.
Sternoclavicular joint
- Only bony attachment between the upper limb and the axial skeleton
- lacks bony stability
- Stability achieved by capsuloligamentous restraints and the disc
- The ligaments that provide this stability are the anterior SC ligament, posterior SC ligament, interclavicular and costoclavicular ligaments.
- typically dislocated anteriorly but can happen posteriorly (
AC joint
- lots of issues with the AC joint
- often gets hot spots, can get arthritis on it. Especially in contact sports.
- With injury to these ligaments- we see the end of the clavicle rises higher. One will be higher than the other and will see a gap with subluxation.
Rhythm of the scapula
- 2:1 ration overall (glenohumeral: scapulothoracic)
- During the first 60 degrees of flexion or the initial 30 degrees of abduction, the scapula does not move much and is seeking a position of stability in relation to the humerus (setting phase)
- During this setting phase the GH joint is the primary contributor to movement.
- With increasing range of motion, the scapula increases its contribution to motion and the scapulohumeral ratio may approach 1:1 during this time.
- If the scapula isn’t moving then we have to do work on it.
Glenohumeral joint
- Articular surface
- Synovial ball and socket articulation
Joint stability is provided by:
=rotator cuff
=long head of biceps brachii
=extracapsular ligaments
- the labrum deepens the socket and gives some stability to the joint. If torn the head will pop in and out.
- shoulder dislocation is a result of ligament laxivity or ligament tears.
Rotator cuff muscles
- Supraspinatus
- most commonly torn ligament in the rotator cuff- highly susceptible to injury and to being pinched.
- Infraspinatus
- is the second most common pinched or torn rotator cuff muscle.
- Teres minor
- Subscapularis
Supraspinatus
- initiates abduction
- It is the anchor of the shoulder
- Deltoid is a big and powerful muscle and the direction of pull is right into the acromion- if not balanced by the supraspinatus it would shove up into the acromion.
- If torn, cannot reach over the head. Cant go beyond 90 degrees and starts to pinch at 60 degrees.
force couple
- muscles with opposite actions that work together to produce rotation.
- 2 force couples in the shoulder. (upper and lower trap-external rotation, supraspinatus and deltoid are both force couples)
Shoulder impingement
- An umbrella term in that includes any pathological change which occurs under the coracoacromial arch including rotator cuff tears and describes several degrees of muscle injury from compression or tears that result from impingement.
- Mechanism of injury is usually gradual onset, history of overuse, especially overhead activity.
Impinged or pinched?- supraspinatus or long head of the biceps.
Shoulder impingement structures
- Suprapinatus
- Long head of the biceps
- The subacromial bursae- bursitis, highly innervated, hurt when get inflamed
- On occasion the infraspinatus
- The labrum and joint capsule (internal impingement)
- —–Structures on underside of joint labrum and capsule can get pinched.
impingement of bursa
the bursa is highly innervated
Biceps impingement
inflammation occurs where biceps tendon passes through bicipital groove and over the head of the humerus, just like a rope through a pulley.
Causes of impingement
- Instability of the glenohumeral joint: weakness, capsule and joint laxity
- Dyskinesia (scapula not moving in correct rhythm with humeral head)
- Poor posture
- Arthritis- can get uneven surfaces- bumps on it, grows osteophytes going down off of the acromion and stick into the subacromial space and get a little dagger into the supraspinatus. Don’t want to be doing resistance overhead exercises (just need to be functional overhead)
- Anatomical predisposition.
External and Internal impingement
External impingement: Rotator cuff and/or bursae are getting compressed or pinched on the superior surface by the acromion.
Internal Impingement- The rotator cuff, labrum, or capsule is getting compressed or pinched on the under surface by the humeral head.
Anatomical Acromion types
-Another thing that can make someone susceptible to impingement. The size, shapes, and tilt of the acromion- a persons anatomical make up can contribute.
Type 1- a lot of room
Type 2- Most of us are a type 2 acromion
Type 3- Has a sharp arch- will be very very susceptible to shoulder impingement.
forward head and rounded shoulders
-external rhomboids, serratus, and upper trap, levator scapula, and stretch pec minor
Dyskinesia
-Muscles of the scapula are not working together either from muscle imbalance or neurological motor planning impairment
SICK scapula
- Scapular malposition
- Inferior medial border prominence
- Coracoid pain and malposition
- Dyskinesis of scapular motion
Medical Diagnosis: Diagnositcs
X-ray- look for arthritis, type of acromion, bone wear and tear, dislocation.
MRI- identification of soft tissue structures
MRI with Gadolineum Dye- better image and shows leak in capsule and ligamentous structures
Medical OT examination
-Patient history
-Clinical observations including watching scapular motion
-ROM
-MMT
Special Tests/provocation tests- a whole lot of them.
Painful Arc
When in the arc of motion does pain occur for abduction and flexion, where does it start to hurt.
Hawkins Kennedy Test
Looks at the supraspinatus- sit on matt stabilize shoulder, internally rotate with flexed elbow and shoulder at 90. hold where you arm is at and dont let me move you- push on upper arm. If it hurts in front of a shoulder it is a positive test.
SUPRASPINATUS
-Have them raise arm to 90 and the flex elbow with arm in internal rotation. Stabilize shoulder and then push down. Not going to push hard (just get them to contract). Positive sign would be pain in the anterior shoulder., pain not in the anterior shoulder is still good information to know bout would be negative if not in the anterior shoulder. Do both sides.c
Neer Test
Neer test- make sure their feet can touch the floor, fully internally rotate arm at 90, push down and depress her shoulder while placing her into flexion- if it is painful it is a positive Neer sign (test both sides). Take into full range for flexion or until it is uncomfortable for them (a positive test). Rotator cuff, long head of the biceps, and the bursa can all get impinged.
These tests are provocative- will show shoulder impingement or rotator cuff tear.
Cannot get someone with frozen shoulder into a new position for the Neer test- may be able to get the Hawkins
- Best thing to measure= posture, ROM, scapular mobility, etc.
Full can/Empty can test
Also known as Jobes test
Empty can or full can test- empty can test hurts worse so start with the full can.
Come up into a scapular plane (open packed position) stabilize at shoulder, have hand positioned to grab full can position, push down near the wrist. Empty can is with the wrist pronated and arm internally rotated.
Always start with the full can first. Flex at 90 in the scapular plane, give resistance just distal to the elbow joint, push down enough to get her to contract to see if they have any pain, if positive it is up near the shoulder (anterior). Do both sides
- that is the full can
- this can look at the biceps as well, slap lesion
Empty can-
Arm flexed to 90 in scapular plane in internal rotation- hold don’t let me move you, pain at anterior deltoid is a positive sign.
