DPT731 Shoulder

shoulder flexion & aBd

0-180°

shoulder extension ROM

0-45°

fulcrum, stationary arm, & distal arm for shoulder flexion & extension

fulcrum = greater tubercle, stationary arm = mid-axillary line of thorax, distal arm = lateral epicondyle

fulcrum, stationary arm, and distal arm for shoulder ABD

fulcrum = acromion, stationary arm = parallel to sternum, distal arm = midline to humerus

GH ABD

0-120°

shoulder IR

0-70°

shoulder ER

0-90°

fulcrum, stationary arm, and distal arm for shoulder IR and ER

fulcrum = olecranon process, stationary arm = parallel to floor, distal arm = ulna (ulnar styloid & olecranon)

deltoid MMT and nerve roots tested

-flexion (anterior delt)
-scaption
-ABD
-horizontal ABD (posterior delt)
-axillary nerve (C5-C6)

supraspinatus MMT and nerve roots tested

-flexion
-scaption
-ABD
-suprascapular nerve (C5-C6)

teres minor and infraspinatus MMT and nerve roots tested

-ER
-teres minor = axillary (C5-C6)
-infraspinatus = suprascapular (C5-C6)

subscapularis MMT and nerve roots tested

-IR
-upper & lower subscapular n (C5-C6)

lat dorsi & teres major MMT & nerve roots tested

-IR
-extension
-lat dorsi = thoracodorsal (C7-C8)
-teres major = lower subscap (C5-C6)

pec major MMT

-IR
-horizontal ADD

MMT of horizontal ADD at 60° tests what muscle fibers & nerve?

-clavicular fibers of pec major
-lateral pectoral nerve (C5-C7)

MMT of horizontal ADD at 120° tests what muscle fibers & nerve?

-sternal fibers of pec major
-medial pectoral nerve (C8-T1)

serratus anterior MMT & nerve roots tested

-scapular protraction & upward rotation
-long thoracic (C5-C7)

upper trap MMT

scapular elevation

middle trap MMT

scapular ADD (T)

lower trap MMT

scapular depression and ADD (Y)

rhomboids MMT and nerve roots tested

-scapular ADD & downward rotation
-dorsal scapular (C5)

special test cluster for SAPS

1. hawkins-kennedy
2. neers
3. painful arc
4. empty can (jobe)
5. resisted ER

history and exam findings for high irritability pt's

-pain (7/10)
-consistent night or rest pain
-pain before end of ROM
-AROM < PROM
-high disability

history and exam findings for moderate irritability pt's

-pain (4-6/10)
-intermittent night or rest pain
-pain at end ranges
-AROM ~ PROM
-moderate disability

history and exam findings for low irritability pt's

-pain (3/10)
-absent night or rest pain
-minimal pain w/ OP
-AROM = PROM
-low disability

intervention focus for high irritable pt's

-minimize physical stress
-activity modification
-monitor impairments

intervention focus for mod irritable pt's

-mild-moderate physical stress
-address impairments
-basic level functional activity restoration

intervention focus for low irritable pt's

-moderate-high physical stress
-address impairments
-high demand functional activity restoration

diagnosis cluster of full thickness RTC

1. age > 65
2. + painful arc
3. + infraspinatus muscle test (resisted ER MMT)
4. + drop arm test

special tests that assess for rotator cuff tear of supraspinatus

1. drop arm test (highly specific)
2. ER lag sign (highly specific)
3. resisted ER

special tests that assess for rotator cuff tear of subscapularis

1. lift off/gerbers test
2. IR lag sign
3. belly press test

special tests for labral injury/SLAP lesion

1. biceps load II
2. clunk test
3. o briens active compressive test
4. crank test

special tests for biceps lesion

1. speeds test
2. yergasons test

special tests for anterior instability

1. apprehension test
2. jobes relocation
3. anterior drawer
4. load and shift

special tests for posterior instabilty

1. posterior drawer test
2. jerk test
3. load and shift

special test for inferior/multidirectional instability

sulcus sign

special tests for AC joint injuries

1. o briens compressive test
2. cross body ADD stress test
3. AC shear test

special test for adhesive capsulitis

ER ROM at 0°

what does the GH anterior glide improve

extension and ER

what does the GH posterior glide improve

flexion and IR

what does the GH inferior/caudal glide improve

ABD

what are the positive findings to help rule in SAPS

-pain w/ resisted motion
-weakness
-atrophy (massive tear)
-positive special tests

what are the positive findings to help rule in adhesive capsulitis

-gradual onset; progressive worsening of pain & stiffness
-loss of motion in all planes (ER most limited)
-jt glides/accessory motions restricted

what are the positive findings that help rule in GH instability

-age < 40 years
-hx of dislocation or subluxation
-generalized laxity
-positive instability tests

what are the negative findings to help rule out SAPS

-significant loss of PROM

what are the negative findings to help rule out adhesive capsulitis

-normal motion
-age <40 years

what are the negative findings to help rule out GH instability

-no hx of dislocation or subluxation
-no apprehension w/ motion

criteria for return to sport (typically include)

-full functional ROM
-satisfactory muscular strength & endurance
-adequate static & dynamic stability
-painfree clinical exam

criteria in instability severity index score (more points = more likely to benefit from surgery rather than conservative mgmt)

-20 y/o or younger
-participation in competitive sports
-hill-sachs lesion in ER on AP radiograph
-loss of glenoid contour on AP radiograph
-participation in contact sport or OH sport
-shoulder hyperlaxity anteriorly or inferiorly

what is the major precaution to take after a Bankart repair or capsular plication/shift surgery?

-avoid passive ER >20-30° for 8-12 wks
-avoid active IR for 4-6 wks if subscap involved

indications for capsular plication/shift

-chronic, recurrent instability
-multidirectional
-hx of voluntary instability
-unidirectional w/ clear capsular pattern

sxs of a fracture of unreduced dislocation

-significant trauma
-seizure
-acute disabling pain
-acute loss of motion deformity or loss of normal contour

sxs for neurological lesion

unexplained sensory, motor, coordination, or balance deficits

sxs for visceral pathology

-pain not reproduced w/ shoulder mechanical stress
-pain or sxs w/ physical exertion or respiratory stress
-pain associated w/ GI sxs or ingestion of fatty foods

describe a small/partial thickness RTC tear (<1 cm)

-tear of 1 tendon (usually supra)
-may remain asymptomatic or mild sxs of pain
-no loss of AROM

describe a mod tear/mod thickness RTC tear

-1-3cm
-involve 2 tendons (usually supra & infra)
-more likely to become symptomatic
-may loss AROM

describe a large tear/full/complete thickness RTC tear (3-5 cm)

-tear/tears of 3-4 tendons (supra/infra & subscap or LH biceps)
-symptomatic
-loss of AROM

precautions for post-op arthroscopic RTC repair

-no active motion for 6 wks
-avoid passive IR for 4 wks
-behind back (ADD) w/ IR = not allowed for 8 wks
-allow for RC healing at boney footprint
-50% of re-tears happen in 1st 3 months
-post-surgical stiffness

precautions for arthroscopic subacromial decompression for RTC tear

-post surgical pain (can last up to a year due to bone shaving)
-avoid impingement positions

purpose & indications of superior capsular reconstruction for RTC tear

purpose: tensor fascia autograft to prevent superior migration of humerus
indications:
massive irreparable RTC tear > 5 cm
>/= 2 tendons
intact GH joint

describe a type I SLAP and its intervention

-fraying/degeneration of superior labrum
-intervention = conservative mgmt; maybe debridement of superior labrum

describe a type II SLAP and its intervention

-fraying/degeneration of superior labrum
-biceps tendon detached from glenoid
-interventions = repair superior labrum & biceps tendon tenodesis

describe a type III SLAP and its interventions

-bucket-handle tear of superior labrum
-biceps tendon IS intact
-interventions = surgical removal of bucket-handle tear

describe a type IV SLAP and its interventions

-bucket-handle tear of superior labrum
-biceps tendon torn
-interventions = surgical removal of bucket-handle tear, resection of damaged biceps tendon, reattachment of labrum, repair remaining biceps tendon

list the rehab and precautions of SLAP tear**

-limited A/PROM of ER < 30° for 4-8 wks (peel back lesions)
-immobilized ~4 wks in a sling & ABD pillow in IR
-elbow & hand ROM immediately
-NO biceps strengthening 4-8 wks

what is primary or idiopathic AC/frozen shoulder

-global limitation of humeroscapular motion
-contracture & loss of compliance of GH jt capsule

what is secondary AC

-systemic (thyroid or diabetes)
-intrinsic causes/musculotendinous patho (RTC tendinopathy or tear)
-extrinsic causes (CVA, BP injury)

describe stage I in the freezing/painful phase of AC

-spontaneous onset of pain
-sharp pain at end ranges
-achy pain at rest
-sleep disturbances
-misdiagnosis of SAPS
-can last 1-3 months

describe stage II in the freezing/painful phase of AC

-sharp pain at end ranges
-achy pain at rest
-gradually ↑ stiffness develops
-primarily loss of capsular pattern (ER, ABD, flex)

describe stage III in the frozen/stiff phase of AC

-limited ROM in ER, ABD, flex
-pain at end-range
-stiffness more pronounced (fibrosis of jt capsule present)
-last 9-15 months

describe stage IV in the thawing/resolution phase of AC

-gradual functional recovery
-progressive ↑ in ROM due to reverse capsular pattern (regain flexion 1st)
-normal use of arm & shoulder
-lasts 15-24 months
-some pt's may not fully recover ROM (esp ER)

gradual progressive stretching hold times for high irritable AC/frozen shoulder pt

short hold times (5-10 sec)

gradual progressive stretching hold times for low irritable AC/frozen shoulder pt

-longer hold time (10-60 sec)
-low-load long duration (multiple mins)

what position should AC/frozen shoulder be in when stretching & why

-supine
-stabilizes scapula to bias GH jt capsule

surgical indications for AC/frozen shoulder

persistent global stiffness & pain w/ little improvement despite at least 4-6 months of nonop care

indications for total shoulder arthroplasty (TSA)

-RA
-complex fractures
-OA
-tumors, avascular necrosis

prognosis after TSA

-fair/good: restricted motion & some pain
-still significant ROM deficits at end of rehab but is functional:
-flexion: ~140°
-ER: 25-40°
-IR: hand to gluteal region to lumbar spine

indication for reverse total shoulder

-large irreparable rotator cuff

most common fracture in children

clavicle fx

common location of clavicular fractures

80% occur in medial 1/3 of clavicle

what population are humeral fx most prevalent in

-women with osteoporosis
-incidence increases with age

humeral fracture locations

-greater or lesser tuberosity
-head
-shaft
-surgical neck at distal end of GT & LT

humerus fracture complications

-malunion
-RC damage
-nerve injury (proximal humerus fx = Bplexus w/ axillary nerve most common; diaphysis fx = radial nerve sensory & motor deficits distally)
-arterial injury (anterior/posterior circumflex w/ prox humerus fx or brachial w/ diaphysis fx)

entrapment sites for suprascapular nerve palsy

-suprascapular notch under transverse scapular lig
-spinoglenoid notch by hypertrophied spinoglenoid lig
-spine of scap & medial tendinous margin of infra & supra

sxs of suprascapular nerve palsy

-deep, diffuse, dull aching pain over posterior lateral aspects of shoulder
-supra &/or infra atrophy
-weakness in ER & ABD
-(+) ER lag sign & drop arm sign
-empty can (+) for weakness

sxs of axillary nerve palsy

-loss of sensation around deltoid tuberosity
-atrophy of deltoid
-weakness in all shoulder motions or substitute w/ RC

sxs of spinal accessory nerve palsy

-trapezius atrophy
-winging scap (lateral elevation; shoulder ER against resistance, lateral away from spine)
-pain due to poor scapulohumeral mechanics

sxs long thoracic nerve palsy

-scapular flip sign
-scapular winging (anterior elevation; pushing on a wall; pushups - medial towards spine)
-pain due to poor scapulohumeral mechanics

describe nociceptive pain, its sxs cluster, and examples

-pain related to damage of somatic or visceral tissue, due to trauma or inflammation
sxs cluster:
-proportionate pain
-aggravating & easing factors
-intermittent sharp, dull ache or throb at rest
-no night pain, dysesthesia, burning, shooting
-RA, OA, gout

describe neuropathic pain, its sxs cluster, and examples

-pain related to damage of peripheral or central nerves
-pain in dermatomal or cutaneous distribution
-positive neurodynamic & palpation
-hx of nerve pathology or compromise
-painful diabetic peripheral neuropathy, postherpetic neuralgia

describe nociplastic pain, its sxs cluster, and examples

-pain without identifiable nerve or tissue damage, hypothesized to result from persistent neuronal dysregulation
-disproportionate pain
-disproportionate aggravating & easing factors
-diffuse palpation tenderness
-psychological issues
-fibromyalgia, phantom limb pain, CRPS