3.1 - shoulder general tx. & anatomy

• GH

• AC

• SC

• scapulothoracic

what are the joints of the shoulder 

coracoid process

what bony landmark does the brachial plexus run under

greater tuberosity

what is the most common landmark for shoulder pain

internal; external

the lats does active (internal or external) rotation and could limit (internal or external) rotation

bent 

the lats more tight if the legs are (bent or straight), this can lead to limited shoulder flexion if they are tight 

serratus anterior

the __________ muscle is the main muscle that provides scapular thoracic stability

anterior; winging

a tight pec minor that result in the scapula having a ___________ tilt and __________ winging

motor control 

scapular dumping is a ___________ problem  

upper trap and levator scap

what are the common muscles for shoulder trigger point pain

• GH 

• SC 

• AC 

• ST 

• thoracic spine 

• cervical spine 

joint mobs for the shoulder 

• posterior capsule/cuff (most common)

• pec minor

• upper trap/levator scapula

common STM for shoulder pain

IR

_______ motion is limited with a tight posterior cuff

• teres minor 

• infraspinatus 

what muscles are the contributors to a tight posterior cuff

SC

whats better to mob? SC or AC joint

door stretch with elbow bent 

whats the best stretch for the pec minor 

retraction (pulling down and back → open up chest)

after stretching the anterior shoulder, follow it up with scapular ______ exercises

• cross body abduction - inc. shoulder ROM more

• sleeper stretch

stretch options for posterior shoulder tightness, which increases shoulder ROM more

posterior 

perform __________ glides to improve posterior shoulder tghtness 

anterior

lying on a foam roller addresses (anterior or posterior) shoulder tightness

• pulleys 

• codman’s/pendulums 

• wall walks

examples of shoudler AROM/AAROM 

shoulder instability/hypermobile

what pt diagnosis shouldn’t be given codman’s/pendulums

• tactile cueing

• visual feedback

• scapular assist test

ways to teach pt to elevate shoulder without substitution

allows shoulder to be in scapular plane 

what is the benefit to adding a towel under the arm for a patient in supine 

central 

T-spine and C-spine manipulations are theorized to increase ROM, BUT _______ effects are the likely cause

extension and IR (because painful position,threat to shoulder)

what is the last motion we do to with the shoulder in PT 

manips 

which is better for improving shoulder pain, manips or mobs?

• supine towel 

• supine roller 

• seated thoracic and cervical extension over chair 

• active thoracic extension 

• posture correction 

• cat camel 

• c-spine/upper t-spine retraction (chin tuck)

• c-spine/upper t-spine rotation 

self mob examples 

flexion; extension

during a chin tuck; the upper cervical spine goes into _________ and the lower cervical spine goes into _________

stabilizers; NM 

exercises for shoulder pain should emphasize on ___________ and ___________ control 

• focus on rotator cuff and scap muscles (middle trap, lower trap, serratus anterior)

• minimize

  • upper trap

  • levator scap

when exercising the shoulder, which muscles should you focus on and which muscles should you minimize

supraspinatus

what muscle does full can exercises target

smaller 

when rehabbing the shoulder, start with the (smaller or larger) muscles 

OKC

OKC or CKC shoulder exercise:

functional

CKC

OKC or CKC shoulder exercise:

stability

OKC 

OKC or CKC shoulder exercise:

isolate muscle activity 

lower trap and serratus

what muscles get shut down with shoulder pain

T (perfer pain free but if the minimal pain subsides when exercise is over it is okay)

T/F: you can exercise the shoulder when there is minimal pain during the exercise

isotonics 

which type of exercise is preferred for strengthening/motor the rotator cuff?

• isometric 

• isotonic 

• isokinetic 

provides better blood flow to the cuff and reminder for stability

what is the purpose for the towel being under the elbow during RC strengthening

rotate; elevate

when rehabbing the shoulder, the rule of thumb is __________ before __________

sidelying 

which position is better for shutting down the upper trap…

• standing er

• sidelying er

increases; decreases

full can exercise (decreases or increases) moment arm and (decreases or increases) the supraspinatus force

abduction; flexion

GH elevation during ___________ is not functional and has potential for impingement and GH elevation during ___________ is more functional with less chance of impingement

• IR and ER

• shoulder elevation (flexion, scap, abduction) 

what exercises are best to activate the RC 

serratus anterior and lower trap

the ____________ and _____________ muscles are commonly implicated to activate scapular exercises

prone Y 

what is the testing position for lower trap 

serratus anterior; levator scap

during AROM of exercise/strengthening of the shoulder, reduce muscle activity or scap muscles __________ and ___________

I → T → Y

what is the progression with prone Ys, Is, and Ts

down (shuts down the lats)

palm (up or down) is harder during prone I’s

upper trap

the shoulder W exercise shuts off the __________ muscle

• level 1

  • is it shoulder or not - clear the neck

• level 2 - category…

  • rotator cuff/impingement

  • frozen shoulder

  • GH instability

• level 3

  • high, moderate, or low irritability

what are the levels and sublevels of the “complaint of shoulder sx” level pyramid

• key positives

  • impingement signs

  • painful arc

  • pain with isometric resistance

  • weakness

  • atrophy

• key negative

  • significant loss of motion

  • instability signs

key positives and key negatives of the level 2 classification specific exam for rotator cuff/impingement

• key positive

  • spontaneous progress pain

  • Loss of motion in multiple planes

  • Pain at endr ange

• key negative 

  • normal motion 

  • age < 40 

key positives and key negatives of the level 2 classification specific exam for frozen shoulder 

ER

the hallmark sign of frozen shoulder is significant loss of _______ motion

• key positive

  • Age < 40

  • Hx d/l or sublux

  • Apprehension

  • Generalized laxity

• key negative

  • no history d/l

  • no apprehension

key positives and key negatives of the level 2 classification specific exam for GH instability

• High pain (≥7/10)

• Night or rest pain

  • Consistent

• Pain before end ROM

• AROM < PROM

• High disability

  • DASH

  • ASES

signs/sx of high irritability of the level 3 irritability classification 

pain reducaiton

if a patient is in the high irritability category, the focus should be on _________

• pain reduction

• impairments

• basic function

if a patient is in the moderate irritability category, the focus should be on _________

functional activity 

if a patient is in the high low category, the focus should be on _________

• Mod pain (4- 6/10)

• Night or rest pain

  • Intermittent

• Pain at end ROM

• AROM ~ PROM

• Mod disability

  • DASH,

  • ASES

signs/sx of moderate irritability of the level 3 irritability classification 

• Low pain (≤3/10)

• Night or rest pain

  • None

• Min pain with overpressure

• AROM = PROM

• Low Disability

  • DASH

  • ASES

signs/sx of low irritability of the level 3 irritability classification 

3; 5

need at least ______ out of the ______ signs/sx to categorize someone into an irritability rating

:)

write out the treatment strategy for irritability categories (high, moderate, low)

here are the treatment strategies…

• modalities

• activity modification

• ROM/stretch

• manual techniques

• strengthen

• functional activities

• pt education

• taping/functional support (brace/external)

extrinsic

extrinsic or intrinsic cause of rotator cuff disease:

compression in the subacromial space

intrinsic

extrinsic or intrinsic cause of rotator cuff disease:

tendon is worn down, common with age

extrinsic (posture, shoulder kinematics)

can PT fix intrinsic or extrinsic causes of rotator cuff disease 

posterior/internal

_______________ impingement is a category of rotator cuff disease where compression of the tendons between the posterior rom of the glenoid and the humeral head

posterior/internal or subacromial pain

______________ impingement is common in overhead athletes

anterior lateral

people with subacromial pain 'impingement’ syndrome with have pain located in the ____________ shoulder with OH activities

• hawkin’s

• neer 

• painful arc 

special test for compression/extrinsic subacromial pain ‘impingement’ syndrome

• resisted ER

• full can

• empty can

• painful arc

special test for tension to the cuff causing subacromial pain ‘impingement’ syndrome

• apprehension test and shoulder relocation

special test for internal SAIS subacromial pain ‘impingement’ syndrome

F 

T/F:  general exercise is better than specific exercise

function; pain

exercise vs surgery:

• exercise is better for __________

• surgery is better for ___________

resistance; proprioceptive

______________ and _____________ exercises are better than movement based exercises

• decrease OH/provocative activities (dec pain) 

• AROM 

• stretching 

• strength/motor control 

• posture correction

• manual therapy

• modalities

• MEDS: NSAIDS, injections

• address risk factors with job/ADLs/hobbies

• pt education

genertal treatment during the acute phase of SA impingement 

T

T/F: isotonic exercises is the preferred choice as the muscle functions through the ROM for strengthening/motor control during the acute phase of SA impingement

shrug

__________ is defined as early or excessive upward rotation

dump

__________ is defined as a rapid downward rotation during lowering

• chin tucks/retractions 

• stretch

• strengthen 

exercises to reduce forward head posture 

extension

when address posture for SA impingement, focus on thoracic __________

posterior; lower trap

the theory behind elastic taping for SA “impingement” is increasing __________ tilt and increasing activity of the ____________ muscle

leukotape 

is kinesiotape or leuoktape better for posture correction 

facilitatory = bottom, facilitates lats

inhibitory = top, inhibiting upper trap

which tape is facilitatory and which is inhibitory

sub-acute/chronic

will a patient in the (acute or sub-acute/chronic) phase of SA ‘impingement’ tolerate more stretching

acute = arm is at their side

sub-acute chronic = arm is getting in front, 45-90 degrees

what is the main difference between strengthening treatment between acute and sub-acute chronic

6 weeks

it takes a minimum of _________ for bone to heal