MSK LEC_ SHOULDER

is a multiaxial, ball-and-socket, synovial joint that depends primarily on the muscles and ligaments rather than bones for its support, stability, and integrity (3 DOF)

_____ is a ring of fibrocartilage, surrounds and deepens the glenoid cavity of the scapula about 50% ( Only part of the humeral head is in contact with the glenoid at any one time.

What is the RP and CPP of this joint? What is its Capsular Pattern?

GH joint

Labrum

55° abduction, 30° Horizontal adduction ; CPP: Full ABER

ERabIR

The glenoid in the resting position has a 5° superior tilt or inclination and a 7° retrover- sion (slight medial rotation). The angle between the humeral neck and shaft is about _____, and the humeral head is retroverted 30° to 40° relative to the line joining the epicondyle

130°

The rotator cuff controls osteokinematic and arthrokinematic motion of the humeral head in the glenoid and along with the biceps depresses the humeral head during movements into elevation.

Ligaments of GH joint:

_______ - limits inferior translation in adduction. It also restrains anterior translation and ER up to 45° abduction.

______ - limits ER between 45° and 90° abduction.

______ - The most important ligament. It supports the humeral head above 90° abduction, limiting inferior translation while the _______ band tightens on ER and the posterior band tightens on ______

SGHL

MGHL

IGHL - anterior band , medial rotation

Excessive lateral rotation, as seen in throwing, may lead to stretching of the anterior portion of the ligament (and capsule), thereby increasing glenohumeral laxity.

Ligaments of GH joint:

______ - limits inferior translation and helps limit lateral rotation below 60° abduction.This ligament is found in the rotator interval between the anterior border of the supraspinatus tendon and the superior border of the subscapularis tendon, thus the ligament unites the two tendons anteriorly.

The rotator interval consists of ___________

Injury to these structures can lead to contractures, _______ instability, and _______ instability

CHL

CHL, SGHL, GH joint capsule & tendons of subscapularis & supraspinatus

biceps tendon & anterior glenohumeral

The _______ ligament forms an arch over the humeral head, acting as a block to superior translation.

______ ligaments holds the long head of biceps tendon within the groove.

GH JOINT: Branches of the posterior cord of the brachial plexus and the suprascapular, axillary, and lateral pectoral nerves innervate the joint.

coraco-acromial

Transverse humeral Ligament

______ - is a plane synovial joint that augments the ROM of the humerus in the glenoid (3 DOF). This joint depends on ligaments for its strength. The ______ ligaments surround the joint and control horizontal motion of the clavicle. ( 1ST LIGAMENT INJURED when stressed)This joint is innervated by branches of the suprascapular and lateral pectoral nerve.

Types:

• 1:

• 2:

• 3:

• 4:

About 70% of _______ are associated with a hooked acromion.

The________ ligament is the primary support of the AC joint.

AC joint → acromioclavicular ligament

flat → curved → hooked → convex (uptured)

rotator cuff tears

coracoclavicular ligament

AC JOINT : Coracoclavicular ligament

2 portions: _______ & _____ control the vertical motion of the clavicle.

If a ______ occurs, this ligament has been torn

CPP:

RP:

Capsular Pattern:

Conoid & Trapezoid

step deformity

90° Abduction, Arm resting at side , Pain at Extreme Rom in Full elevation & Horizontal adduction

The _________ joint, along with the AC joint, enables the humerus in the glenoid to move through a full 180° of abduction ( saddle shape w/ 3 DOF). It joins the appendicular skeleton to the axial skeleton.

_____ & _______ , which support the joint anteriorly and posteriorly

________ the main ligament maintaining the integrity of the SC joint

RP:

CPP:

Capsular Pattern:

SC joint ( medial end of clavicle, manubrium sternum & cartilage of 1st rib; also depends on ligaments for it strength)

Ant & Post ligaments

Interclavicular & costoclavicular ligament ( rhomboid ligament)

• Arm resting by side in normal physiologic position

• Full elevation & protraction

• Pain at extremes ROM in horizontal adduction & full elevation

_________ It consists of the body of the scapula and the muscles covering the posterior chest wall and must be considered in any assessment because a stable scapula enables the rest of the shoulder to function correctly.

T or F: When assessing the shoulder, it is important to look not only the shoulder but also the whole kinetic chain ( linkage of multiple segments of the body that allows transfer of forces and motion starting at the feet)

Scapulothoracic joint ( No CPP & Capsular pattern)

True

Rotator Cuff Lesions

• Hx:

• O:

• Active movement:

• Passive movement:

• MMT:

• Special Test:

• Sensory Function:

• Palpation:

• Diagnostic Imaging:

• 30 to 50 years, Pain and weakness after

  eccentric load

• Normal bone & soft tissue outlines, protective shoulder hike may be seen

• Weakness of EXABIR (any) , crepitus may be present

• Pain if impingement occurs

• Pain & weakness on ABER

• Drop Arm & Empty can test +

• Not affected

• Tenderness over rotator cuff

• MRI & Xray: acromial spurring, upward displacement of humeral head

Frozen Shoulder

• Hx:

• O:

• Active movement:

• Passive movement:

• MMT:

• Special Test:

• Sensory Function:

• Palpation:

• Diagnostic Imaging:

• 45+ ( insidious), after trauma or surgery, restricts EXABIR

• Normal bone and soft tissue outlines

• Restricted ROM & Shoulder hiking

• Limited ROM in EXABIR

• Normal when arm by side

• None

• Not affected

• Not painful unless capsule is stretched

• X ray : (-) , Arthrography: DEC capsular size

Atraumatic Instability

• Hx:

• O:

• Active movement:

• Passive movement:

• MMT:

• Special Test:

• Sensory Function:

• Palpation:

• Diagnostic Imaging:

• 10-35, pain and instability c activity, No hx of trauma

• Normal bone and soft tissue outlines

• Full of excessive ROM

• Normal or Excessive ROM

• Normal

• Apprehension, Relocation & Augmentation test: (+); Load & shift test : (-)

• Not affected

• Ant or Post pain

• (-)

Cervical Spondylosis

• Hx:

• O:

• Active movement:

• Passive movement:

• MMT:

• Special Test:

• Sensory Function:

• Palpation:

• Diagnostic Imaging:

• 50+ years ( acute/chronic)

• Torticollis may be present, Minimal or no cervical spine movement

• Limited ROM c pain

• Limited ROM ( symptoms may be exacerbated)

• Normal unless nerve root compressed = myotome

• Spurling, Distraction, ULNT & Shoulder abduction test : (+)

• Dermatomes & reflexes affected

• Tender over appropriated vertebra or facet

• X - ray : narrow osteophytes

Patient History

A fall on out-stretched hand (FOOSH), which could indicate a _________

A blow to the tip of the shoulder, or land on the elbow, driving the humerus up against the acromion may indicate an ___________

T or F: Patients with instability may appear normal on clinical examination, especially if shoulder muscles are not fatigued.

Persons who had recurrent dislocations/instability of the shoulder may find that any movement involving______ bothers them, because this movement is involved in anterior dislocations of the shoulder.

fracture or dislocation of shoulder

acromioclavicular dislocation or subluxation.

True

ER

Patient History

Long head of biceps pathology causes pain that moves ____________

Excessive ________ may lead to dead-arm syndrome - sudden paralyzing pain and weak- ness in the shoulder.

This finding often indicates altered shoulder mechanics commonly involving a tight posterior capsule, altered arthrokinematics of the glenohumeral joint, and scapular dyskinesia. In throwers, the condition may be referred to as a ______

If the patient complains of pain during specific phases of pitching (for example, during the late cocking and acceleration phases),______ should be considered even in the presence of minimal clinical signs.

ER & IR of the shoulder

ABIR

“SICK” scapula

anterior instability

SICK Scapula is?

• Malpositioned Scapula

• Inferior medial border of scapula prominence

• Coracoid pain & malposition

• Scapular dysKinesia

Cause of Primary Impingement Syndrome

• Inflammation in subacromial space

• Rotator cuff tendon degeneration

• Osteophytes under AC joint

• Hooked acromion

• Glenohumeral joint hypermobility

impingement or pinching is the primary cause of the pain

• >40 , degenerative

Cause of Secondary Impingement Syndrome

• Abnormal glenohumeral arthrokinematics

• Abnormal scapulothoracic arthrokinematics

• “Slouched” posture

• Muscle weakness or fatigue

• Muscle hypomobility

• Capsule tightness especially posterior

implies that although impingement signs are present, they result from a primary problem somewhere else, commonly in the scapular or humeral control or stabilizer muscles.

• 15-35 yrs old

• scapula dyskinesia & altered muscle dynamics

Impingement

_______ In the older patients, this impingement occurs due to degenerative changes to the rotator cuff, acromion & coracoid process, anterior tissues from stress overload

______ In 15-35 y/o , anterior shoulder pain is primarily caused by muscle imbalances and abnormal movement patterns

______ a type of impingement found posteriorly mostly in overhead athletes and involves contact of rotator cuff ( Supra & Infra) with the posterosuperior glenoid labrum when arm is abducted to 90° and ER fully.

Primary Impingement

• occur anteriorly

Secondary Impingement

• presents instability of scapula or GH joint

  • occur anteriorly

Internal/Non-outlet impingement

• occur posteriorly

T or F: Stability of the shoulder depends on both dynamic stabilizers (the muscles) only

False, Stability of the shoulder depends on both dynamic stabilizers (the muscles) and static stabilizers (e.g., the capsule, labrum)

Patient History

Night pain and resting pain are often related to _____ and, on occasion, to ___; activity-related pain usually signifies _______. _____ commonly shows, at least initially, at the extremes of motion.

Acromioclavicular pain is especially evident at _______and tends to be localized to the joint. Similarly, sternoclavicular pain is localized to the joint and increases on ______

rotator cuff tears or tumors

paratenonitis

Arthritis pain

> 90° abduction

horizontal adduction

Patient History

deep, boring, toothache-like pain in the neck, shoulder region, or both may indicate ______ OR _____

Strains of the ______ usually cause dull, toothache-like pain that is worse at night, whereas ________ usually causes a hot, burning type of pain.

_________ are often seen in skiers and may result from holding on to a ski tow; in cross-country skiing, it may result from poling . Paratenonitis is inflammation of the paratenon of the tendon (outer covering of the tendon whether or not it is lined with synovium) Tendinosis is actual degeneration of the tendon itself. With chronic overuse,________ is more likely to be present

thoracic outlet syndrome or acute brachial plexus neuropathy

Rotator Cuff strains

acute calcific tendinitis

bicipital paratenonitis or tendinosis

tendinosis is more likely than paratenonitis

Patient History

Patients with nerve root pain may find that ________ relieves symptoms.

For a patient with instability or inflammatory conditions, _________ usually exacerbates shoulder problems

If the limb tires easily, it may indicate _______. Pressure maybe applied in 3 locations : scalene triangle, at the costoclavicular space, and under the pectoralis minor and the coracoid process.

elevating the arm over the head

lifting the arm over the head

vascular problem ( TOC - can be caused by excessive repetitive demands placed on shoulder)

Patient History

If there is atrophy and paralysis of the supraspinatus and infraspinatus muscles → _______ nerve affected or _______

Dislocation of GH joint could affect ________ → atrophy/paralysis of _______

Fracture to humeral shaft can affect → _______ ( extensors of the elbow, wrist, and fingers are affected and sensation distribution)

Suprascapular nerve or 3rd degree rupture of supraspinatus tendon

Musculocutaneous nerve or axillary nerve → deltoid & teres minor

Radial nerve

Observation

T or F: As part of the observation, noting whether the patient can assume a “neutral pelvis” position is important, because an abnormal pelvic position can lead to an abnormal scapulothoracic, glenohumeral, and cervical spine position and abnormal kinematics in these joints.

True

Observation: Ant View

• Ensure ____ & ____ are in midline

• Forward Head posture is often associated with _____ shoulders, a medially rotated humerus and a protracted scapula resulting in the humeral head translating _____, a tight ____ capsule, tightness of the ____ ,_____, and _____, and weakness of the lower scapular stabilizers and deep neck flexors.

• ________ a deformity may be caused by an acromioclavicular dislocation with the distal end of the clavicle lying superior to the acromion process

  • both the ______ & _____ ligaments have been torn.

  • _____ is evident anterior to AC joint

  • ______ indicates that degeneration has caused communication between the acromioclavicular joint and swollen subacromial bursa underneath

• If a ______ appears when traction is applied to the arm, it may be caused by multidirectional instability or loss of muscle control due to nerve injury or a stroke, leading to inferior subluxation of the GH joint ( deformity is lateral to acromion)

• Flattening of the normally round deltoid muscle area may indicate an ___________ or _____ of the deltoid muscle

• head and neck

• rounded shoulders, humeral anterior translation, posterior capsule; tightness of pectoral, upper trapezius, and levator scapulae

• Step deformity → acromioclavicular and coracoclavicular ligaments torn ( can be check in IR and bring hand up or horizontal adduction )

  • swelling → Fountain sign

  • sulcus deformity

• anterior dislocation of the glenohumeral joint or paralysis

Observation: Ant View

• In anterior dislocation, If the examiner palpated in the ____, he or she would feel the head of the humerus.

• If the patient is protective of the shoulder, however, it may appear that the injured shoulder, whether dominant or nondominant, is _____ than the normal side

• Assume normal functional position of shoulder _________

  • In this position, or with the arm abducted to 90°, rupture or congenital absence of the_______ may be evident

• Rupture of the _______ is often accompanied by a tearing sensation and pop along with weakness, painful LOM and ecchymosis ( bruising).

• If the patient’s arm is in IR from this position to bring the hand into midline, the biceps tendon is forced against the lesser tuberosity of the medial wall of the bicipital groove. If this position is maintained for long periods, there may be increased wear of the biceps tendon, which can lead to ____________

• If the arm is horizontally adducted while it is medially rotated, anterior pain indicates ______

• Wider grooves allow the tendon too much lateral movement, leading to ___________ , the deep grooves tend to be too narrow, compressing the tendon, especially if it becomes _______.

• axilla

• higher

• 60° of abduction and the arm in neutral or no rotation

  • pectoralis major

• bicipital tendinitis or paratenonitis

• impingement symptoms ( Hawkins Kennedy Test)

• Paratenonitis; tendinitis

Observation: Post View

• Atrophy of the upper trapezius may indicate ________, whereas atrophy of supraspinatus or infraspinatus may indicate _________ palsy

• Test used to measure scapular position ______. Measuring from the spinous processes horizontally to 3 scapular positions: the medial aspect of the most superior point (superior angle), the root of the spine of the scapula, and the infe- rior angle

• If the scapula is sitting lower than normal against the chest wall, the superior medial border of the scapula may “washboard” over the ribs, causing a ________ during_________

• _________ can lead to altered GH joint angulation, abnormal stress on shoulder liga- ments, altered subacromial space, overload of the AC joint, INC strain on the scapular stabilizing muscles, altered muscle activation, and modified arm position and motion

  • These alterations are commonly the result of an excessively _______ scapula during arm motion.

• spinal accessory nerve palsy; supraspinous nerve

• Lennie’s Test

• snap during ABAD

• Scapular dyskinesia

  • protracted

Observation: Post View

Scapular Dyskinesia Types:

• Type 1: shows the________ being prominent at rest and the inferior angle tilts _____ with movement (scapular tilt), while the acromion tilts ____ over the top of the thorax.

  • If the inferior border tilts away from the chest wall, it may indicate the presence of _______,____, & _____ or tight _____

• 2: classic winging of the scapula with the _______ of the scapula being prominent and lifting away

  • May indicate presence of ______ to _____ lesion & weakness of

• 3: _______ of the scapula being elevated at rest and during movement; . This deformity is seen with active movement and may result from overactivity of the ______ & _____ along with imbalance of the upper and lower trapezius force couple. Associated with impingement and rotator cuff lesions

• 4: both scapulae are ______ at rest and movement. they rotate symmetrically upward with the inferior angles rotating laterally away from midline . It is seen during movement and may indicate that the scapular control muscles are not stabilizing the scapula.

• inferior medial border prominent, dorsally , anteriorly ( Scapular Tilt & Maybe seen during concentric/eccentric movement)

  • Weak L traps, Lats & SA or tight Pecs Minor

• whole medial border prominent ( Maybe seen during concentric/eccentric movement)

  • SLAP lesion to biceps lesion & weakness of SA, Rhomboids, TRAPS, Long thoracic nerve or tight humeral rotator

• Superior border → Levator & traps( minimal winging in shoulder shrug)

• symmetrical scapulae

Observation: Post View

• _________ - winging is the result of muscle weakness of one of the scapular muscle stabilizers that, in turn, disrupts the normal muscle force couple balance of the scapulothoracic complex.

• _________ - implies that the normal movement of the scapula is altered because of pathology in the glenohumeral joint.

• ________ - (winging by movement) can be cause by a lesion of long thoracic nerve affecting serratus anterior, trapezius palsy (spinal accessory nerve), rhomboid weakness, multidirectional instability, voluntary action, or a painful shoulder resulting in splinting of the glenohumeral joint, which in turn causes reverse scapulohumeral rhythm.

• ________ - causes the scapula to depress and move laterally with the inferior angle rotated laterally. If the trapezius is weak or paralyzed, the winging of the scapula occurs before 90° abduction, and there is little winging on forward flexion

• ________- causes the scapula to elevate and move medially with the inferior angle rotating medially

  • Winging of the scapula occurs on abduction and forward flexion

• Primary scapular winging

• Secondary Scapular winging

• Dynamic scapular winging

• Spinal accessory nerve palsy

• Long thoracic nerve palsy

Observation: Post View

• ________ - (winging occurring at rest) is usually caused by a structural deformity of the scapula, clavicle, spine, or ribs

• _________ - developmental condition leading to a high or undescended scapula, most common congenital deformity of the shoulder complex. (uni or bilat.)

  • Dec abduction

• _______ - wasting of supraspinatus & infraspinatus can lead to winging of scapula

• Static winging

• Sprengel’s deformity

• Suprascapular nerve palsy

Examination : T or F

If If the examiner has any doubt as to the location of the lesion, a cervical spine assessment should be done

Scapular instability may be evident in open kinetic chain when the arm is fixed and the rotator cuff muscles work in reverse order (reverse origin- insertion)

In open kinetic chain, the scapula acts as the base or origin of the muscles, whereas the insertion into the humerus is more mobile

True

False, evident in CKC

True

Differential Diagnosis of Shoulder Pathology

Pathology → Symptoms

1. ________ → >35 with Intermittent mild pain with overhead activities

2. __________ → Mild to moderate pain with overhead activities or strenuous activities

3. ______ → Pain at rest or with activities , Night pain may occur & Scapular or rotator cuff weakness

4. Rotator cuff tear (full thickness) - ____ pain → Weakness of ____ & _____ and

   Loss of _____

5. Adhesive Capsulitis (idiopathic frozen) → Inability to perform ___ (LOM maybe perceived as weakness)

6. Anterior instability (with or without external secondary impingement) → ______ to mechanical shifting limits activities ( ____ capsular pattern), _______ may present as instability , ________ pain may be present & Weak scapular stabilizers

1. Stage 1 External primary impingement

2. Stage 2

3. Stage 3

4. Classic night pain ; Weakness in abduction and lateral rotators & Loss of motion

5. Inability to perform ADLs owing to loss of motion

   Loss of motion may be perceived as weakness

6. Apprehension to mechanical shifting limits activities usually in HORABER

   Slipping, popping, or sliding may present as suitable instability rotation

   Anterior or posterior pain may be present

   Weak scapular stabilizers

Differential Diagnosis of Shoulder Pathology

Pathology → Symptoms

1. Posterior instability → _______ of the humerus out the back, associated with ______ & _____ while shoulder is under a compressive load

2. Multidirectional instability → Looseness of _____ in all directions, most pronounced while _______ or _______ & Pain _______

1. Slipping or popping of the humerus out the back

   This may be associated with forward flexion and medial rotation

2. Looseness of shoulder in all directions, most pronounced while carrying luggage or turning over while asleep & Pain may or may not be present

AROM

T or F : Shoulder movements may also involve the thoracic spine and ribs.

True

Force Couples About the Shoulder

AROM : Painful Arc

most commonly by _______

• 45-60° : abduct arm with little difficulty

• 60-120° : ______ is impinge ( glenohumeral painful arc )

• 120-160° : painless

• 170- 180° : _______ or ____

an unstable scapula

subacromial bursa, rotator cuff tendon insertions, especially supraspinatus

acromioclavicular painful arc(localized ) or impingement syndrome (ant shoulder region)

Classification of Glenohumeral Painful Arcs

Anterior

• Night Pain

• Age

• Sex

• Aggravated By

• Tenderness

• AC joint involvement

• Calcification

• 3rd degree strain biceps (long head)

• Porgnosis

• Yes

• 50+

• Female

• ABER

• lesser tuberosity

• No

• calcification SI_S muscles

• No

• Good

Classification of Glenohumeral Painful Arcs

Posterior

• Night Pain

• Age

• Sex

• Aggravated By

• Tenderness

• AC joint involvement

• Calcification

• 3rd degree strain biceps (long head)

• Porgnosis

• Yes

• 50+

• Female

• ABIR

• Posterior aspect of greater tuberosity

• No

• Supra / Infraspinatus

• No

• Very GOOD

Classification of Glenohumeral Painful Arcs

Superior ( most common)

• Night Pain

• Age

• Sex

• Aggravated By

• Tenderness

• AC joint involvement

• Calcification

• 3rd degree strain biceps (long head)

• Porgnosis

• Maybe

• 40+

• Male

• Abduction

• Greater tuberosity

• Often

• Supraspinatus and subscapularis

• Occasional

• Poor (without surgery)

Scapulohumeral Rhythm

Phase 1: No 2:1 ratio yet

• Humerus :

• Scapula :

• Clavicle :

This setting phase means that the scapula may rotate slightly in, rotate slightly out, or not move at all.

• 30° abduction

• minimal movemet (setting phase)

• 0-5° elevation

Scapulohumeral Rhythm

Phase 2:

• Humerus :

• Scapula :

• Clavicle :

Thus, there is a 2:1 ratio of scapulohumeral movement.

• 40° abduction

• 20° rotation, minimal protaction or elevation

• 15° elevation

Scapulohumeral Rhythm

Phase 3:

• Humerus :

• Scapula :

• Clavicle :

the angle between the scapular spine and the clavicle increases an additional 10°. Thus, the scapula continues to rotate and now begins to elevate.

during this final stage, the humerus finishes its lateral rotation to 90° so that the greater tuberosity of the humerus avoids the acromion process.

• 60° abduction, 90° lateral rotation

• 30° rotation

• 30-50° posterior rotation , 15° elevation

Summary of Scapular Kinematics During Arm Elevation in Healthy and Pathologic States

Mechanisms of Scapular Dyskinesia

If the clavicle does not rotate and elevate, elevation through abduction at the glenohumeral joint is limited to ____

If the glenohumeral joint does not move, elevation through abduction is limited to ___

If there is no lateral rotation of the humerus during abduction, the total movement available is ____, 60° of which occurs at the glenohumeral joint and 60° of which occurs at the scapulothoracic articulation.

120°

60°

120°

_________ means that the scapula moves more than the humerus. This occurs in conditions like the frozen shoulder. The patient appears to “hike” the entire shoulder complex rather than produce a smooth coordinated abduction movement.

Reverse Scapulohumeral rhythm

Active elevation (170° to 180°) through the plane of the scapula (30° to 45° of forward flexion), termed scaption, is the most natural and functional motion of elevation

Doing the rotation testing in 90° abduction (if the patient can achieve this position) will give a clearer indication of true glenohumeral joint medial and lateral rotation, which are measured when the scapula starts to move .

If rotation is tested in 90° abduction and crepitus is present on rotation, it indicates abrasion of torn tendon margins against the coracoacromial arch and is called the “______

abrasion sign.

Normally, any gain in lateral rotation is commonly accompanied by a comparable loss in medial rotation.

A GIRD can lead to → ______ →

GERD → ________

______ caused by scapula rubbing over the underlying ribs

Posteroinferior capsule → SLAP lesion

shoulder problem

Snapping scapula

Functional ROM Combined Test

_______ combines medial rotation with adduction and lateral rotation with abduction

Note: Often, the dominant shoulder shows greater restriction than the non-dominant shoulder, even in normal people. An exception would be patients who continually use their arms at the extremes of motion

Muscles that are tight in ant shoulder instability : _______ while ______ weak

Apley’s scratch test (scratch at back)

subscapularis, pectoralis minor and major, LATS , upper trapezius, levator scapulae, SCM, scalenes, and rectus capitus.

serratus anterior, middle and lower trapezius, infraspinatus, teres minor, posterior deltoid, rhomboids, longus colli, and longus capitus.

Causes of Scapular Imbalance Patterns

Humeral Movement Faults

Indications of Loss of Scapular Control

Scapular Winging Faults

Winging of the Scapula: Dynamic Causes and Effects

Signs and Symptoms of Possible Peripheral Nerve Involvement

Passive Movements of the Shoulder Complex and Normal End Feel

Subcoracoid bursitis may limit full lateral rotation, and subacromial bursitis may limit full abduction because of compression or pinching of these structures.

Resisted Isometric Movements

T or F: The scapula should not move during isometric testing. Scapular protraction, winging, or tilting during isometric testing indicates weakness of the scapular control muscles.

3rd degree strain (rupture) of the long head of biceps tendon presents ______ sign when testing isometric elbow flexion

True

Pop-eye sign

Muscles About the Shoulder: Their Actions, Nerve Supply, and Nerve Root Derivation

Muscles About the Shoulder: Their Actions, Nerve Supply, and Nerve Root Derivation—cont’d

Range of Motion Necessary at the Shoulder to Do Certain Activities of Daily Living

:)

Palpation : Anterior

• Clavicle - make sure it is in its resting position in injured side.

• SC joint - also palpate the ligaments & SCM

• AC joint - ligaments, muscles ( traps, deltoid, subclavius)

• Coracoid Process: In ______ syndrome is very tender

• Sternum

• Ribs & Costal Cartilage

• Humerus & SITS

• Axilla

SICK scapula syndrome

Palpation : Posterior

• Spine of scapula

• Scapula

• Spinous processes of lower cervical & thoracic spine - trapezius

Differential Diagnosis of Shoulder Instability (AMBRI) versus Traumatic Anterior Dislocation (TUBS)

T or F: A hypermobile or lax joint does not imply instability.

True

Instability and Pseudolaxity Impingement

_______ - In the older patient (40-years-old or older), mechanical impingement occurs because of degenerative changes to the rotator cuff, the acromion process, the coracoid process, and the anterior tissues from stress overload resulting in impingement.

_______ - In the young patient (15 to 35-years-old), anterior shoulder pain is primarily caused by problems with muscle dynamics with an upset in the normal force couple action leading to muscle imbalance and abnormal movement patterns at both the glenohumeral joint and the scapulo- thoracic articulation.

_______ - This type of impingement is found posteriorly rather than anteriorly, mostly in overhead athletes. It involves contact of the undersurface of the rotator cuff (primarily supraspinatus and infraspinatus) with the posterosuperior glenoid labrum when the arm is abducted to 90° and laterally rotated fully.

primary impingement

Secondary impingement

Internal impingement

T or F:

If a patient exhibits posterior instability , multidirectional instability is also present

ERABIR results to posterosuperior impingement

True

False, ABER

Labral Tear

In young, _____ stress when applied to GH joint results to injury

Tear maybe ______ where anteroinferior labrum is torn or _______ when superior labrum is affected

_____ lesion occurs commonly with a traumatic anterior dislocation leading to anterior instability

anterior

BANKART lesion → IGHL stability lost

SLAP

BANKART ( 3-7 O CLOCK)

Labral Tear

______ Occurs when the poster GH dislocation occurs and results in labrum detached from 6-9 o clock

_____ lesion that occurs in 10-2 O clock position,caused by FOOSH, decceleration when throwing or when sudden traction is applied in bicpes

Reverse Bankart lesion

SLAP lesion

Types of SLAP LESION

• 1

• 2 (Most Common)

• 3

• 4

A _____ mechanism results in a posterior TYPE 2 SLAP lesion in overhead athletes, INC ER, DEC IR and tight posterior capsule = tear in posterosuperior labrum

• Superior Labrum strained but intact

• Small tear in SL + instability of labrum-biceps complex

• Bucket handle tear of labrum that displace into joint; labral biceps attachment intact

• Bucket handle tear of labrum that extends to the biceps tendon, allowing tendon to sublux into joint

REFLEX

often assessed reflex are 😀

• C5-C6 → Pecs major and clavicular portion; biceps

• C7,C8,T1 → sternocostal

• C7-C8 → triceps

Peripheral Nerve Injuries of the Shoulder

_______- MOST COMMONLY INJURED nerve in the shoulder.

MOI : _______

Muscle: _____,______

Axillary nerve

Anterior dislocation/ fracture of humeral neck

Deltoid & Teres Minor

Peripheral Nerve Injuries of the Shoulder

_______ -Injury from a fall on posterior shoulder, stretching, repeated microtrauma or fracture of scapula

Muscle: ______,______

Suprascapular nerve

Supraspinatus & infraspiantus

Peripheral Nerve Injuries of the Shoulder

______ - Injured due to humeral dislocation, fracture

Muscle : ____,______

Musculocutaneous nerve

biceps,brachialis,coracobrachialis

Peripheral Nerve Injuries of the Shoulder

_______ - Injury from repeated microtrauamtic activities

Symtpoms: _____,_______,______

Long thoracic nerve

SA weakness, medial winging of scapula and weakness on forward flexion

Peripheral Nerve Injuries of the Shoulder

_______ - traumatic injury

Symptoms: affect trapezius, shoulder drooping and lateral scapular winging

Spinal accessory nerve

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