Ther-Ex Exam II

Shoulder conditions most popular (in order)

1. Rotator cuff pathology (tendinopathy, tears, rotator cuff shoulder pain)

2. Glenohumeral and acromioclavicular osteoarthritis

3. Frozen shoulder

4. Long head of bicep

5. Labral tears (SLAP)

6. Instability

Four joints of shoulder

Glenohumeral

Acromioclavicular

Sternoclavicular (only connection from shoulder to body)

Scapulothoracic *not a true joint

Mobility is bought with stability! (ball on a golf tee)

Static stabilizers for shoulder

Glenoid labrum: deepens socket by about half

• like fish lips→ suctions on to humerus→ negative pressure inside the joint

Capsule and glenohumeral ligaments

Superior ligament and coracohumeral ligament

• stretched when arm at side

Middle ligament

• stretched with anterior translation in mid range abduction

Inferior ligament

• stretched with anterior and inferior translation at 90 degrees abduction and external rotation

Subacromial space of shoulder

Roof: acromion, coracoacromial ligament, coracoid

Floor: humeral head

Contents: supraspinatus tendon, subacromial bursa, long head of biceps

Narrows with elevation

• Continued compression associated with pain

• Could lead to subacromial decompression

Dynamic stabilizers of shoulder

Rotator cuff: compresses the humeral head into the glenoid

*lose the rotator cuff→ head rides up under acromion

Deltoid: lifts and the cuff holds the head centered

Long head of bicep: helps anterior stability

Scapular muscles: position the socket under the head

Glenohumeral arthrokinematics

convex head on concave glenoid: roll slide go opposite

• Abduction: superior roll, inferior slide

• Flexion: mostly spin

• External rotation: posterior roll anterior slide

Scapulothoracic motion

Scapula moves because clavicle moves at SC and AC joints

• SC joint is VERY STRONG

Elevation and depression

Protraction and retraction

Upward and downward rotation

Upward rotator of scapula

serratus anterior, upper and lower trapezius

Downward rotators of scapula

rhomboids, levator scapulae, pectorialis minor

Normal ROM for shoulder

Flexion: 160-180

Extension: 50-60

Abduction: 170-180

Adduction: 50-70

External rotation: 70-90

Internal rotation: 60-90

*compare to other side

Throwers internal and external rotation shoulder

Throwers often have more external, less internal on throwing arm

Scapulohumeral rhythm

180 degrees of elevation (120 GH and 60 scapulothoracic)

• 2:1 ratio after first 30 degrees (first 30 all GH)

Clavicle rotates posteriorly as arm rises

Age shoulder interview

Age:

• Under 30: instability

• 40-60: frozen shoulder and cuff

• 60+: osteoarthritis and degenerative tears

Onset shoulder interview

Onset:

• Trauma: dislocation, acute tear, fracture

• Gradual: tendinopathy, osteoarthritis, frozen shoulder

Location shoulder interview

Location:

• Lateral delt: cuff or cervical

• Anterior: bicep, AC joint

• Deep: labrum, osteoarthritis

• Between shoulder blades: cervicothoracic

Night pain, overhead sports shoulder interview

Night pain: common with frozen shoulder and osteoarthritis

Constant change that does not change with position=red flag

Overhead work or sport: cuff, labrum, biceps

Red flags shoulder interview

deformity, unable to lift arm after a fall→ fracture

numbness, tingling or weakness in hand after trauma→ axillary nerve

left shoulder or arm pain with exertion, SOB→ cardiac

Right shoulder or scapular pain after meals→ gallbladder

Constant progressive pain that position does not change→ tumor, cancer

fever, hot swollen joint→ infection

Dosing a high irritability painful shoulder

Pain 7/10

Night pain wakes them

Goal: calm symptoms, keep motion

Mobility: pain free PROM and AAROM

Manual therapy: grade 1 and 2 glides, distraction

Dosing: isometrics, 3-4 RIR

Dosing a moderate irritability painful shoulder

Pain 4-6, some night pain

Goal: restore motion, begin loading

Mobility: AROM, stretching to tolerance

Manual therapy: grade 3 slides

Dosing: light resistance

Dosing a low irritability painful shoulder

Pain 0-3, only with overpressure or after activity, no night pain

Goal: build capacity, return to task

Mobility: full range under load

Manual therapy as needed

Dosing: heavy slow resistance, power, task practice

Rotator cuff related shoulder pain

Umbrella term: tendinopathy, partial tears, bursitis, used to be called impingement

Pain and weakness with ELEVATION and EX ROTATION, usually with no single injury

Not one structure: muscle, tendon, bursa

Pain does NOT equal structural damage

Influenced by sleep, stress, work, beliefs about the shoulder

How common is shoulder pain?

3rd most common MSK complaint

• 70% of this is rotator cuff related

• Most cases start 40-60

Rotator cuff tendinopathy

Load exceeds tissue capacity

• Intrinsic: age, reduced blood supply near insertion, tendon degeneration

• Extrinsic: repeated compression under coracoacromial arch, overhead work

Risk factors: age over 40, overhead occupation or sport, smoking

Supraspinatus #1, Infraspinatus #2

Shoulder tendiopathy

pain in overhead positions, lying on shoulder

weakness from pain

diffuse pain over anterolateral shoulder and deltoid

better once warmed up

range mostly full, painful arc 60-120 degrees

Rotator cuff tears acute

Younger patient, often a FALL

Sudden, pop, immediate weakness

Cannot lift arm after fall

Early surgical opinion

Rotator cuff degenerative tears

40 and older, no single event

Gradual pain, night pain

Manage with exercise first, surgery if it fails

Shoulder application rotator cuff

Tissue healing: tendinopathy is a load problem

Mobility: keep full range

Motor control: practice the task, external focus, vary load and angle

Dosing: isometrics 20-45s for pain, heavy slow resistance

Deltoid

P: lateral 1/3 of clavicle, acromion, scapular spine

D: deltoid tuberosity of humerus

Action: anterior deltoid abducts and flexes GH joint, middle deltoid abducts GH, posterior deltoid adduction and extension of shoulder, IR, post deltoid ER

Biceps brachii

P: LHB-supraglenoid tubercle, SHB-coracoid process of scapula

D: radial tuberosity

Action: long head flex GH joint

Latissimus Dorsi

P: spinous process of T7-T12, inferior angle of scapula, 9-12 ribs, iliac crest

D :floor of intertubercular sulcus

Action: ST joint depressor, should adduction and extension, IR

Rotator cuff muscles

SITS. Supraspinatus, infraspinatus, teres minor, subscapularis. Help create roll slide in abduction. 

Trapezius

P: occipital bone, spinous process C1-C7, aponeurosis T1-T4, spinous process T5-T12

D :lateral 1/3 of clavicle, acromion, scapular spine

Action: upper trapezius elevates ST joint. lower trap depresses ST joint. Middle and lower trapezius retracts ST joint, upper and middle trap upward rotate ST joint

GH joint elevators

muscles for abduction (anterior deltoid, middle deltoid, supraspinatus) and muscles for flexion (anterior deltoid, coracobrachialis, long head of bicep)

Shoulder adductors and extensors

pectoralis major, latissimus dorsi, teres major, posterior deltoid, long head of tricep

Shoulder internal rotators

subscapularis, anterior deltoid, pectoralis major, latissimus dorsi, teres major

Shoulder external rotators

infraspinatus, teres minor, posterior deltoid

Pain that is not from the shoulder

Neck refers pain into the shoulder and between the shoulder blades

C5 and C6→ refer to deltoid and lateral arm, same place cuff pain lives

Lower cervical level→ interscapular region

Neck and shoulder are married

Neck movement, sustained neck position changes the shoulder pain

Symptoms travel below elbow and into hand

Pain with coughing or sneezing

Glenohumeral and AC joint osteoarthritis

Loss of cartilage, changes in bone and capsule

No clear cause

• secondary to trauma

• instability

• massive cuff tear

• avascular necrosis

Risk factors shoulder OA

shoulder injury, history or shoulder problems

repetitive occupational stress, especially overhead

age over 50

women more than men

metabolic disorders, obesity

90% of people with OA have at least 1 risk factor

Patient reports shoulder OA

worse in the morning, loosens with movement

night pain (wakes them)

deep pain in joint

worse after exercise

crepitus, catching

loss of IR and ER

TSA vs rTSA

Total shoulder replacement vs reversed total shoulder replacement

TSA: replace the ball (top of humerus)

rTSA: switch the ball and socket

• if rotator cuff muscles are very degraded, they can’t assist roll slide correctly

• rTSA allows for deltoid to just take over and lift arm (roll slide happen same direction)

OA shoulder patient application

Tissue healing: chronic condition, inflammatory flares

Mobility: PROM and AAROM, respect the hard end feel

Manual therapy: Grade 1 and 2 for pain, grade 3 for motion

Motor control: task specific reaching and lifting in the available range

Dosing: strengthening 2-3 days per week

Frozen shoulder (adhesive capsulitis)

Inflammation of capsule (synovitis), then thickening and tightening (fibrosis)

Coracohumeral ligament and rotator interval contract

Gradual stiffness and pain over 1-3 months

night pain

ER lost first and most, then abduction and elevation

Passive and active motion are EQUALLY limited: this is the giveaway

Who gets frozen shoulder

40-60

women more than men

idiopathic (we don’t why people get it)

about 1 in 5 later get it later in the other shoulder

Stages of frozen shoulder

Freezing (painful): 2-9 months. Pain, at night, motion falling *not much can be done

• forcing motion does NOT help

• corticosteroid injection best short term evidence

Frozen (stiff): 4-12 months. stiffness, pain settling

Thawing: 5-24 months. Motion slowly returns

Whole course: 9 months- 4 years

Long head of biceps pathology

tendon runs inside the joint, over humeral head, anchors on superior labrum

Could be tendinopathy, subluxation out of the groove, rupture

Rarely alone (often with cuff)

Anterior shoulder pain, pain with overhead reaching

Rupture: a sudden pop, bruising, a bulge in the upper arm

Older adults with a rupture usually do well without surgery

Labral Tears

SLAP: Superior Labrum Anterior to Posterior, at the biceps anchor

Overhead throwing (anchor peels back in late cocking), a fall on an outstretched hand (FOOSH)

deep, vague pain, clicking or catching, dead arm in throwers

Common in overhead athletes

superior labral changes appear on MRI in most pain free adults over 40

non-operative first

Two kinds of instability

TUBS vs AMBRI

TUBS

Traumatic

Unilateral

Bankart lesion (usually with Hill-Sachs)

First Treatment: Reduction, protection, then rehab.

If it fails: bankart repair, bone procedures with bone loss

Bankart lesion

the anteroinferior labrum and ligament tear away from glenoid

• present in 9/10 first time dislocations

Hill Sachs lesion

a compression fracture of the posterolateral humeral head where is struck the glenoid rim

Bony Bankart

the glenoid rim breaks, more bone loss means more recurrence

AMBRI

Atraumatic

Multidirectional

Loose capsule, generalized laxity, often Bilateral

First treatment: Rehabilitation

If it fails: Inferior capsule

Traumatic anterior dislocation

About 95% of dislocations are anterior

Arm abducted and externally rotated (fall, tackle, throw)

Severe pain, arm held at side

Recurrence depends on age

about 3 in 4 under 20 dislocate again

• younger, male

about half between 20 and 40

Multidirectional instability

Symptomatic instability in two or more directions without a major injury

• loose capsule and generalized joint laxity, often both shoulders

• easy dislocation

younger, more often female (swimmers, gymnasts, overhead athletes)

aching, apprehension overhead, subluxations

Rehab first: scapular and cuff control programs

3 joints in elbow

Humeroulnar joint: flexion and extension

Humeroradial joint

Proximal radioulnar joint: pronation and supination

ONE capsule surrounds all three

• coronoid process blocks posterior translation of the ulna

• olecranon locks into its fossa in full extension

Elbow ligaments

Medial (ulnar) collateral ligament

• anterior band: restraint to valgus stress

• posterior band: taut in flesion

Lateral collateral ligament complex: restraint to varus stress

Annular ligament: holds the radial head against the ulna, allows the radius to spin

Nerves through elbow

Median

• through cubital fossa

• between two heads of pronator teres

Ulnar

• behind the medical epicondyle in cubital tunnel

Radial

• splits at elbow into superficial sensory branch and deep motor branch

• deep branch passes through the radial tunnel and supinator

Muscles that flex the wrist

Flexor tendon: medial epicondyle

• flexor capri radiallis, flexor carpi ulnaris, flexor digitorum superficialis, palmaris longus, pronator teres

Extensor tendon: lateral epicondyle

• extensor carpi radialis brevis, extensor digitorum, extensor digit minimi, extensor carpi ulnaris

Arthrokinematics of elbow

Flexion and extension: concave on convex, roll and slide in same direction

Forearm rotation: radius rotates around a fixed ulna

• radial head spins inside the annular ligament

ROMs of elbow

Flexion: 145-150

Extension: 0 to 5 of hyperextension

Pronation: 80

Supination: 90

Carrying angle: relaxed arm resting angle

• 10-15 degrees in men

• 15-20 in women

Most daily tasks ROM requirements

30-130 degrees of flexion

about 50 degrees of pronation and supination

Red flags for the elbow

• FOOSH→ could be fracture or dislocation

• Deformity, bony tenderness, swelling after fall

• Numbness, weakness, cold hand→ nerve

• pop with bruising at front of elbow→ distal biceps rupture

• hot, red, swollen elbow→ infection

• constant pain that position does not change, night pain→ tumor

• neck pain, arm symptoms that change with neck movement→ neck

Lateral elbow tendinopathy

tennis elbow, lateral epicondylitis

• common extensor tendon, most often extensor carpi radialis brevis

load exceeds tissue capacity

degenerative more than inflammatory

repetitive gripping and wrist extension

work, tools, racquet sports

Who gets Lateral elbow tendinopathy?

1-4% of adults

peak age 40-60

Over half still report symptoms at one year

Risk factors: smoker, more than 2 hrs per day of repetitive wrist and elbow motion, manual labor, tennis

Interventions lateral elbow tendinopathy

thoracic rotation- may help indirectly

external rotation (extensor isometric)

mobilize w/ movement

counterforce brace (pins muscle down, new proximal attachment)

corticosteroid injection: no better unless extreme symptoms

Load lateral elbow tendinopathy

Main muscle: extensor carpi radialis brevis

• isometric wrist extension, as gets less irritable slow, heavy wrist extension and supination

• eccentric emphasis

• plan for 12 weeks

change grip diameter on tools and racquets

Medial elbow tendinopathy

golfers elbow, medial epicondylitis

• common flexor and pronator tendon

repetitive gripping, wrist flexion, pronation

golfers, throwers, manual laborers

interventions and load for medial elbow tendinopathy

same as lateral!

Ulnar nerve entrapment (elbow)

Entrapment sites: medial intermuscular septum, cubital tunnel, guyon’s canal at the wrist

Typical Cause: sustained elbow flexion, leaning on the elbow

Median nerve entrapment (elbow)

Entrapment sites: pronator teres, flexor digitorum superficialis arch, carpal tunnel at wrist

Cause: repetitive forceful pronation and gripping

Radial nerve entrapment (elbow)

Entrapment sites: spiral groove, arcade of froshe, supinator

Cause: saturday night palsy, arm draped over back of chair

Nerve entrapment interventions

Ulnar:

• educate about elbow position at rest

• Exercise: ulnar nerve glide progressions, supine shoulder abduction on foam roller, scalene stretch

Median:

• educate about reducing repetitive pronation and gripping

• exercise: stretch into supination and extension

Radial:

• educate that a one time compression will improve on its own

• exercise: radial nerve glides, pronation and supination

Olecranon Bursitis

swelling of bursa at the tip of the elbow

Cause: repetitive pressure, trauma, gout, infection

• jobs with prolonged pressure

• infection (1/3 of cases, refer)

should resolve in 3-8 wks

Osteoarthritis (elbow)

Uncommon.

almost all men, mean age 50

after trauma, years of heavy manual work, lifting

Osteoarthritis (elbow) interventions

joint mobilization

load management

strengthen surrounding muscle to absorb force

NSAIDs

OA vs RA

OA=degenerative

• usually one elbow

• activity usually eases symptoms

RA= inflammatory and systemic

• usually both elbows

• flares can be random or triggered by activity

• be gentle during flares, increase strength between flares

*the elbow is common place for RA

Valgus load in throwing

late cocking and acceleration→ high valgus stress

leads to tension in UCL, flexor and pronator muscles, medical epicondyle

lateral side→ compression of radial head

Skeletally immature: the growth plate and bone fail

Skeletally mature: ligament fails

Little league elbow

young overhead throwers

medial side: medial epicondyle apophysitis or avulsion fracture (ligament rips bone out of socket)

lateral side: compression injury to capitulum

• panner disease

• osteochondritis dissecans

• also with upper extremity weight bearing (gymnastics)

Amount of pitching is strongest risk factor (not pitch type)

Little league elbow interventions

significant reduction in overhead throwing for 4-6 wks

improve throwing mechanics

• thoracic mobility

• shoulder mobility

• task specific proximal stability

Return to throwing in graded steps

load management- pitch counts and rest days

lateral involvement- refer to orthopedics

UCL tear

skeletally overhead throwers, high school and up

Acute on chronic: repeated valgus overload

25% of major league pitchers

Partial tear: trial of rehabilitation first

UCL sprain interventions

Grade 2 sprain

Acute: 0-3 wks. protect, no stretching. maintain available range, isometrics

Subacute: 2-6 wks. full acute range without valgus load. progressive strengthening

RTP: 6-12 wks. full range with increasing load. sport specific practice

Elbow dislocation

highest in adolescent males, nearly half in sport

fall on outstretched hand in older adults

POSTERIER is most common

MCL usually injured, image for fracture, especially of coronoid process

elbow dislocation interventions

brief immobilization near 90 degrees

early motion: more range at 6 weeks, return to work

wrist and forearm strengthening

Heterotopic ossification: bone forms in soft tissue around the capsule. WATCH FOR THIS

RTS: 6-12 wks

Nursemaids elbow

children age 1-4, most often 2

radial head subluxation: the annular ligament slips over radial head

Caused by a pull on the arm, fall, twist

outside rehab scope of practice (reduction)

Distal biceps rupture

sudden eccentric load on the flexed elbow

risk factors: smoking, high BMI

far less common than rupture of the proximal long head

Distal bicep interventions

surgical repair needs to happen within first 6 weeks (tendon will go too far up in arm over time, won’t be able to stretch back out)

After repair: healing takes 3-4 months

Wrist joints

Radiocarpal joint, midcarpal joint, distal carpometacarpal joints

Proximal carpal row

Scaphoid, lunate, triquetrum, pisiform

• relatively loose

Distal carpal row

trapezium, trapezoid, capitate, hamate

• relatively tight and rigid

Degrees of freedom in wrist

Two degrees of freedom

• Because of ulnar tilt: you get more ulnar than radial deviation (run in to bone on radial side)

• Because of palmar tilt: you get more flexion than extension

Circumduction combines all of them (hand in circle)

ROM of each direction in wrist

Flexion: 80

Extension: 70

Radial deviation: 20

Ulnar deviation: 40

Roll slide in wrist

Convex carpals on concave radius

roll slide happen opposite directions

Grip and the wrist

Finger flexors also flex wrist

• wrist extensors must counterbalance them

Max grip: about 30 degrees of wrist extension, 5 degrees ulnar deviation

• optimal length tension

• flexed wrist=weakens grip

Hand muscles, bones, joints

29 muscles, 19 bones, 19 joints

• built for precision

Three arches hold and shape the hand around objects

Carpometacarpal joints: 1st, 4th, 5th more mobile. 2nd and 3rd more stable

Thumb joint

Saddle joint

• abduction and adduction: roll slide happen opposite

• Flex and extend: roll slide happen same direction

Types of grip

power grip, precision grip, key pinch, tip to tip, pulp to pulp, hook grip

Red flags for wrist

FOOSH w/ deformity, swelling, bony tenderness→ refer for imaging

radial wrist pain after a fall: a scaphoid fracture can be missed on first radiograph

Numbness, weakness, cold hand after trauma

Hot, red, swollen joint→ infection

prolonged morning stiffness, swelling in both hands→ refer to rheumatology

progressive weakness or muscle wasting in hand

neck pain, hand symptoms that change with neck movement→ screen neck