12 - Shoulder

what are some symptoms of lat tightness?

anterior pelvic tilt, spine extension

how to test for lat tightness?

if there is more shoulder elevation when knees are bent compared to straight, indicates tight lats

what attaches to the coracoid process?

pec minor, coracobrachialis, coracoacromial ligament, SH biceps

what muscle gets tight with poor posture?

pec minor

what muscles are often overused with shoulder pain?

upper trap and levator scap

what is resting position of the glenohumeral joint? CPP?

resting: 60º abd, 30º horizontal flex, 60º elbow flex with forearm 30º from horizontal plane (arm in sling position → allows for better blood flow)

CPP: 90º abd, full ER with elbow flexed 90º or in full extension, adduction, IR

what are the motions of the humeral head on the glenoid?

rotation: elevation, IR/ER, horizontal abd/add

translations: superior/inferior, medial/lateral, anterior/posterior

abduction elevation humeral rotation and glide (theory and evidence)

rotation: superior

glide theory: inferior

glide evidence: sup → inferior or centered

flexion elevation humeral rotation and glide (theory and evidence)

rotation: superior

glide theory: inferior posterior (to clear acromion)

glide evidence: inf/centered ant →post

IR/horizontal add humeral rotation and glide (theory and evidence)

rotation: anterior

glide theory: posterior

glide evidence: anterior

ER/horizontal abduction humeral rotation and glide (theory and evidence)

rotation: posterior

glide theory: anterior

glide evidence: posterior

what is the scapular plane?

30-45º of the frontal plane

what is the scapulohumeral rhythm?

ratio of motion between humerus and scapular during arm elevation

0-30º abd: has minimal scapular movement

≥30º: 2:1 ratio of humerus:scapula

where does motion in the clavicle occur?

SC and AC joint

what are the convex concave rules of the SC joint in the sagittal and frontal plane? what is CPP of SC joint?

sagittal: opposite rolls and glides

frontal: same rolls and glides

T/F the SC joint has an articular disc and shares a capsule with the 1st rib

T

clavicle glides inferiorly __º and retracts __º.

clavicle moves __º to every __º of humeral motion.

without the SC joint motion, you could only elevate approximately ___º

20, 20

4, 10

100

does the AC joint have strong capsule articulation? strong ligamentous support? when does the AC joint close?

no, yes

full elevation, horizontal shoulder adduction, shoulder IR

during elevation, the clavicle upwardly rotates through axis on acromion approximately __º.

30

what other joints should you assess besides the GH joint?

ST, AC, SC, cervical/thoracic spine and ribs

what are some shoulder self-report measures?

DASH, ASES (American Shoulder and Elbow Surgeon’s Shoulder Evaluation), SPADI (Shoulder Pain and Disability Index), Penn (University of Pennsylvania Shoulder Self-Report)

what are history questions to ask during evaluation?

MOI

athletic/rec activities

neck pain

sx in scapula or below elbow (pain above elbow or in neck often shoulder issue)

popping, clicking, catching

pain with overhead activities

shoulder pain after meals/recent trauma to abdomen

sx aggravated/alleviated by sleeping on shoulder (if pt feels relief sleeping on affected side, often a greater issue)

what does R shoulder pain after meals possibly indicate? what does L shoulder pain after accident/trauma possibly indicate?

gall bladder

spleen

review C4, 5, 6, 7 dermatomes and facet referral patterns

pain in scapula and posterior aspect of shoulder is more likely to be of ____ origin. symptoms of numbness and tingling especially extending to the hand are more likely to be of ____ origin. Referral of infraspinatus can be to _____ and supraspinatus to _____.

cervical, cervical, distal forearm, hand

ddx: pain referred to L shoulder/chest/clavicle region can be what problem?

heart

hx: HTN, heart disease, DM, HLD, smoking family hx

presentation: SOB, increased HR, sweating, chest tightness, arm pain/paresthesis

ddx: pain in left shoulder (Kehr’s sign: L shoulder p! with lying down and legs elevated) usually post trauma, hypotension

spleen

could also be liver and kidneys

ddx: pain in R scapular usually onset after eating

gallstones

risk factors: >40 yo, obese, females, fertile

ddx: pain in shoulder/lateral scapula, extending down medial aspect of arm, 4th and 5th digits, forearm/hand weakness, tingling/numbness, Horner’s syndrome

lung/diaphragm (Pancoast tumor)

ddx: shoulder/arm pain, tingling/numbness, most common along distribution of ulnar nerve, 3 main sites of compression (b/w anterior and medial scalene, clavicle and 1st rib, pec minor)

thoracic outlet syndrome

ddx: fever, weight loss, increased temp, fatigue

systemic signs, could be cancer

what are some yellow/red flags?

pain reduced with sleeping on shoulder - pulmonary pleural irritation

no difficulty sleeping (most pts have difficulty)

shoulder pain not alleviated by rest

insidious onset and pain can’t be reproduced

systemic signs/sx

what is upper cross syndrome? what muscles are tight?

tight: pec major and minor, suboccipital muscles

weak: deep neck muscles, scapular muscles (mid and lower trap, lev scap)

what is a sign of poor posture?

unable to elevate arms over head, may compensate with extended back

what are irregular scapulohumeral rhythms to watch out for?

tipping

winging - serratus anterior

dumping - lack of eccentric control, lev scap, serrative weakness

shrug - torn rotator cuff, can’t elevate shoulder

what causes scapular winging?

weak serratus anterior, weak middle/lower trap, tight pec major/pec minor, tight scapulohumeral muscles

what causes scapular anterior tilt?

tight pec minor, tight biceps, weak middle/lower traps, weak serratus anterior

what are the muscles involved in scapular upward rotation

upper trap, lower trap, serratus ant

what causes scapular downward rotation?

weak upper trap, weak lower trap, weak serratus ant, tight levator scap, tight rhomboid, tight pec minor

ULTT: how to test for median nerve?

shoulder depression/abduction, elbow extension, forearm supination, wrist extension, finger extension, contralateral cervical SB

ULTT: how to test for ulnar nerve?

shoulder depression/abduction, elbow flexion, forearm pronation, wrist extension/radial deviation, finger extension, shoulder ER, contralateral SB

ULTT: how to test for radial nerve?

shoulder depression/abduction, elbow extension, forearm pronation, wrist flexion/ulnar deviation, finger flexion, shoulder IR, contralateral cervical SB

what is impingement syndrome (SAIS)?

theory is mechanical compression of structures in the SA space

could also be due to degeneration of tendon/bursae secondary to overuse and aging

what is the roof, floor and contents of the subacromial space?

roof: inferior acromion surface, CA ligament, coracoid process, AC joint

floor: greater tub, humeral head

contents: supraspinatus, subacromial bursa, long head of biceps, capsule

what are the types of classification of the etiology of SAIS?

Neer’s classification - age and tissue related

primary vs secondary - cause of SAIS

intrinsic vs extrinsic - cause defined by location: contents in the SA space or outside the SA space

what are the stages in Neer's Classification of SAIS?

stage I: edema/hemorrhage of bursa and cuff, <25 yo

stage II: fibrosis and tendinitis of cuff/bursa, 25-40 yo

stage III: partial/full tears of the rotator cuff, bone spurs, >40 yo

what are the primary vs secondary causes of SAIS?

primary: direct compression of RTC, biceps, bursa. cause is an intrinsic or extrinsic factor, ex: “hooked” acromion, RCT

secondary: caused by another pathology such as GH instability or glenoid labral tear

how to identify primary impingement?

>50 yo, degenerative changes, DJD of AC joint, bursitis, tendinitis/tendinosis - atrophy/weakness, biceps tendinitis, scap dyskinesias

how to identify secondary impingement?

<30 yo, anterior/anterolateral pain, repetitive OH use, issue with static stabilizers (capsule/labrum) and dynamic stabilizers (cuff) is fatigued/weakened

what are intrinsic causes of SAIS?

degeneration/inflammation within tendon/bursa. this can be due to overuse or age related vascular and metabolic changes

rotator cuff weakness or motor control issues. decreased strength or muscle imbalance of ER, IR, or both due to overuse, aging, faulty ST kinematics and possibly poor posture. result in disruption of force couple of deltoid (humeral head translates superiorly causing impingement). ER/IR with RC weakness, deltoid

what is the vicious cycle of impingement?

RC weakness causing impingement causing pain causing more weakness

what are some extrinsic causes of SAIS?

scapular muscle weakness, muscle imbalance, motor control issues. caused by instability or faulty control of ST articulation, faulty GH kinematics, poor posture, inhibition secondary to cervical/thoracic pathology

how does C-spine and T-spine affect SAIS?

forward head changes L-T relationship of muscles → scapular muscle issues

T-spine flexion is associated with altered scap kinematics and decreased GH abduction force → scapular muscle issues

how does poor posture affect GH motion?

GH joint has decreased motion

what is posterior capsule tightness? causes?

humeral head has increased superior and anterior translation

cause: altered GH kinematics affecting scap kinematics, increased tone in infraspin

is it possible to isolate PCT in a test? what are some tests you could use?

no, tests measures shoulder complex

GH IR in supine, horizontal add w/scap retraction, post shoulder tightness test

what is posterior shoulder tightness test?

pt is in supine, passively IR and measure before anterior shoulder lifts from table. need to compare bilaterally

what is normal horizontal add with scap retraction (both supine and SL)?

94º horizontal adduction

what scapular dyskinesias are related to reduced SA space? what are humeral dyskinesias are related to reduced SA space?

reduced posterior tilt, ER, upward rotation during GH elevation

increased anterior and superior humeral head translation during elevation

what are the types of acromial morphologies? do they predict RC disease?

type I: flat

type II: smooth

type III: hooked

poor reliability

what is the acromial angle? what is its significance?

angle between the spine of scapula and acromion process

associated with RC tears and SAIS

OS acromiale is a condition where distal epiphysis is unfused

how does aging affect SAIS?

tendons degenerate and cumulative trauma can occur from overuse. increased incidence of RC tears

AC joint degenerates and osteophytes in inferior surface of acromion and SA space

bursa thickens, associated with chronic inflammation

how might your SAIS dx change depending on the age of a pt?

older with SAIS may likely also have degenerative changes

younger with SAIS more likely has GH instability and labral tear

mx history of IS?

predisposing factors like sports/work with repeated overhead activities

often insidious onset of sx, but also sx with onset with activity

slow onset of sx

pain w/activity and provocative positions

pain distribution is typically local but can be referred in C5,6

examining IS - what should your typical findings be for SAIS in pain, type of pain, palpation, A/PROM, painful arc, strength, posture? what special tests should you use?

pain location: local, C5,6 dermatome (assess C-spine)

pain type: sharp w/provocative movements (overhead, cross body, behind back)

palpation: pain of RC tendons

A/PROM: limitation dependent upon pain w/ROM, edema, length of sx

painful arc: pain with elevation from 60-120º, best position of supraspinatus impingement is 60º flex, 60º abd, IR

strength: pain with resisted abduction and ER

special tests: Hawkin’s, Neer, painful arc, horizontal adduction, posterior impingement

painful arc:

pain/sx with 60-120º of abd often associated with? pain/sx with 160/70-180º of abd?

SAIS and RCT (SAIS most common in mid ROM)

AC joint, SAIS, RCT tears

what is the Hawkin’s test?

tests for SAIS

stabilize scap, place elbow at 90º flex and max IR

+ is pain/sx in superior/lateral arm at end ROM

what is the horizontal adduction test?

tests for RC, SAIS, AC

horizontal adduct arm

+ pain at anterior/superior shoulder

ddx: pain at AC joint is AC joint dysfunction

what 3 tests point to SAIS? what is LR?

Hawkins, Painful arc, pain/weakness with ER resistance

+LR of 10.56 if all 3 tests are +

-LR of 0.17 if all 3 tests are –

does SAIS often occur in isolation?

no, your examination should rule out other shoulder disorders like GH instability, GH tightness, labral tears, FT-RCT

what are the types of RCT?

partial thickness - impingement syndrome category

full thickness - all the way through top to bottom

• small: <1cm, medium: 1-3 cm, large: 3-5 cm, massive: >5cm

what is more common, FT or PT RCT?

partial thickness 2x more common

what is hx of RC-FT tear?

age, patients >60/65 yo have increased chance

night pain

previous hx of shoulder pain

same complaints as SAIS - lateral/superior shoulder pain, pain with overhead activities

what tests should you do to check for RC-FT tear?

strength tests: weak abd w/full or empty can tests (supraspinatus), weak ER

special tests: Neer may be +, drop arm test, painful arc, lift off test, ER lag sign, full can/empty can

what is the drop arm test?

tests RTC, supraspinatus

ask pt to abduct to 90º and lower arm slowly, no need to do if pt already demonstrates ability to abduct

+ is pain and difficulty lowering arm slowly

tests for FT tears, SAIS (very painful)

what is the lift off test?

tests subscapularis FT-tear or joint capsule tightness

hand at sacrum/LB, ask pt to lift hand away from the back

+ is inability to lift off from back

what is the belly press test?

tests for subscap tear

max IR - press hand into belly

+ is weakness, inability to maintain IR (wrist flexes, elbow drops back, shoulder extends)

what is the ER lag sign?

tests for RTC tear

at 0º abd, 90º elbow flex, passive ER shoulder as far as possible then have pt hold position

+ if unable to maintain full ER, “lags” back to less than full ER

what is the full can/empty can test?

humeral ER and IR resistance

empty can tests for supraspinatus tear

full can tests for RTC

what are 3 s/sx that have a high LR for RCT?

age >65

weakness in ER

night pain

what are 4 s/sx that have high LR of FT-RCT?

age ≥60

+ painful arc test

+ drop arm test

+ infraspinatus test

what are tissues involved in GH instability?

capsule, GH ligament, CH ligament, RC, deltoid, neural

sublux vs dislocation?

sublux: partial popping then going back in

disloc: head pops out fully

what is common MOI for instability?

anterior and inferior displacement

FOOSH (posterior), overhead pressure (ant/inf), arm out to side

*the longer the joint is dislocated, the harder is to put back in socket

what are signs of GH instability?

sulcus sign, visible/popping acromion, sublux of humeral head

TUBS vs AMBRII classification of GH instability?

TUBS: traumatic, unilateral/unidirectional, Bankart lesion, Surgery required to stabilize (most common is anterior dislocation)

AMBRII: atraumatic, multidirectional instability, bilateral involvement, rehab is first option then surgery, inferior capsule and rotator interval (insignificant trauma)

what is a Bankart tear?

anterior-inferior labral tear associated with anterior instability and dislocation

what is Hill-Sach lesion?

humeral head defect of the posterior-lateral aspect with anterior dis/instability, typically occurs over time

reverse Hill-Sachs is anterior-medial defect with posterior dis/instability

anterior GH instability is usually due to?

apprehension position (abd/ER), cocking and acceleration phase of throw, overheads and serves (tennis, volleyball)

posterior GH instability is usually due to?

positions of flex, add, IR, FOOSH injuries

multidirectional instability is usually due to?

inferior traction of humerus and generalized laxity

instability - what to observe in mx hx?

patient <40 yo

history of repetitive overhead activity, primarily associated with anterior instability

traumatic or insidious

direction: MOI, sx with activity or position of feeling of instability

recurrent sublux: w/activity, “dead arm syndrome”, paresthesia

what to look for in examination for GH instability?

does it sublux or dislocate with exam?

determine direction of instability in mx hx to determine which test to use

does it dislocate voluntarily

assess labral tear

Hill-Sachs or reverse

nerve damage

what happens with impingement of axillary nerve?

atrophy and weakness of deltoid

what are special tests for GH instability?

anterior instability - load and shift, apprehension, anterior release, relocation

posterior instability - load and shift, posterior apprehension

inferior/multidirectional instability - sulcus, accessory joint testing (ant, post, inf), rule in/out additional dx like labral tears, SAIS, lift-off test with ant/inf instability

what is the sulcus test?

tests for multidirectional instability

pt sitting, place traction on humerus at elbow

+ is space between acromion and HH as compared bilaterally (graded 1+ to 3)

what is the load and shift test?

tests capsule and labrum, anterior/posterior instability and glenoid labral tears

load the humerus into the glenoid then ant/post translate

+ is amount of translation and click for labral tear

what is the apprehension test?

tests for anterior instability

pt is supine or standing, first abd 90º then gradually ER the shoulder maximally

+ is apprehension or sx reproduction

what is anterior release test?

apply posterior force with arm in 90/90 position

+ is apprehension/pain with released force

what is posterior internal impingement test?

tests for impingement usually of infraspinatus/supraspinatus at posterior superior edge of glenoid

may be associated with anterior instability more common with overhead athletes