Shoulder

traps, delts, pecs

the prime movers of the shoulder are _____, ______, and _____

dynamic stability

the function of the Rotator Cuff is ___________

stability

For scap ________, the traps, rhomboids, levator scap, and serratus anterior all work together

supraspinatus, infraspinatus

______ and _____ insert on the greater tuberosity

subscapularis

_______ inserts on the lesser tuberosity

long head of biceps

the groove on the proximal humerus houses what tendon

short head of biceps, coracobrachialis, coracoclavicular lig., pec minor

Coracoid process is the insertion point for:

• (supraspinatus/short head of biceps)

• (infraspinatus/coracobrachialis)

• (coracoclavicular lig./costoclavicular lig.)

• (pec minor/pec major)

are not

the posterior cuff muscles (are/are not) distinct bands of insertion on the proximal humerus

long

the (long/lateral/medial) head of the triceps attaches on the infraglenoid tubercle

lateral

the (long/lateral/medial) head of the triceps attaches on the posterior humerus

olecranon process

the triceps insert on the __________ of ulna

lower traps, serratus anterior

when shoulder pain is present, the ______ and ______ will be inhibited

lats

the ______ help the shoulder extend and internally rotate → flexion and end range elevation can stretch this muscle

upward rotation, posterior tilt

the function of the serratus anterior is _________ and _________ and ER of the scap → it is to help protract the scap around the thoracic wall and to prevent winging

70 deg, inactive

Below ~ _______ SA is (inactive/active)

pec minor

If the ________ is restricted, the medial border and inferior border of the scap will begin winging → poor posture plays a role

Glenohumeral Joint

________ is characterized by:

• ball and socket jt

• convex head on concave fossa

• 1/3 - ½ of head fits into fossa

ABD, horiz. FL, flexion

the resting position for the GH jt is 60 deg of _____, 30 deg of ______, 60 deg of elbow _____ with forearm 30 deg from horizontal plane

ABD, ER, FL, EX, ADD, IR

the close-packed position for the GH jt is 90 deg of _____, full _____ with elbow ______ 90 deg OR full _______, _______, _______

instability

the close-packed position of the GH jt is a position of ligament ________ where the joint is in a position for dislocation

Rotations

_____ of the GH joint include elevation, IR/ER, and horiz. add/abd

Translations/Glides

_____ of GH jt include sup/inf, medial/lateral, ant/post

do not

IR/Hor. ADD and ER/Hor. ABD (do/do not) follow the normal convex concave rules because of the size of the ball in the socket

Scapular Rotations

______ include IR/ER, Upward Rotation/Downward rotation, Ant/Post tilt or tip

Scapular Translations/Glides

______ include sup/inf (shrug) and ant/post (protraction/retraction)

Scapulohumeral Rhythm

_____ is the ratio of motion b/w humerus and scapula (upward rotation) during arm elevation (2:1 - humerus:scapula)

below, does not

(below/above) 30 deg of abd the scapula (does/does not) move a lot

concave, convex; convex, concave

SC jt is _____ on _____ in the sagittal plane and _____ on ______ in the frontal plane

full elevation

SC joint is in closed packed position with _______

inferiorly, retracts

During active elevation, clavicle glides ______ and ______ 20 deg

Hor. ADD, Full elevation, IR

______ and ______ and ______ will close down the AC joint

full shoulder elevation

Things that can cause issues with _______:

• Gh jt

• scapular mov’t

• SC jt

• AC jt

• Spine

shoulder elevation

For bilateral __________ these things are necessary:

• cervical side bend same

• thoracic opposite side bend and rotation to same side

• thoracic EX

• Lumbar EX

DASH

Disabilities of Arm, Shoulder, and Hand is shortened to ______ with an error with a single score of 8 and a MDC of 13

FOOSH

______ is falling on an outstretched hand and is a common MOI of shoulder/wrist/hand injuries

facets

If symptoms are in scapula, there might be an issue with the ______ in the C spine

neck

If symptoms are below the elbow, look at the _____ for issues

alleviated, abnormal

Symptoms that are ________ while sleeping on involved side are considered ______

C4-C7

________ dermatomes cover shoulder, arm, and scapula

inferior angle, neck

If pain is above _______ of scapula, look at the _____

C5 & C6, C5

______ myotomes and ______ dermatome are areas of pain referral in the AC jt and Subacromial Space

scapula, posterior

Pain in _____ and _______ shoulder is more likely due to cervical issue

cervical

Numbness and tingling (even more so with extending the hand) are usually from ______ region

forearm, hand

Referral of infraspinatus can be to distal ______ while supraspinatus can refer to the _____

heart

the _____ can refer to the L shoulder/chest/clavicle region

s/sx: SOB, incr. HR, sweating, chest tightness, arm p!/paresthesias

spleen, emergency, shock

If the _____ is injured, it is an ______ as the injury will not cause death but the _____ of the injury will

Kehr’s Sign

____ is pain referred to the left shoulder from a spleen injury usually post trauma → hypotension is usually associated

cholecystitis, gallstones

______ is pain referred from _______ to r scapula after eating

• risk factors: >40 yo., obese, female, fertile

lungs, diaphragm, ulnar

the ____ or _____ (Pancoast tumor) can refer pain to the shoulder or lateral scapula → pain can extend down medial aspect of arm/4th/5th digits mimicking _______ nerve

• s/sx: forearm/hand weakness and tingling/numbness

• Horner’s syndrome (can affect facial muscles)

Thoracic Outlet Syndrome, ulnar

______ is shoulder/arm pain with tingling/numbness along _______ nerve distribution (C8/T1)

• b/w ant. and med. scalene

• clavicle and 1st rib

• pec minor

Malignancies

For possible ______ (breast cancer or lung cancer), look for hx of CA and get lab work to rule out metastases

• systemic signs: fever, weight loss, incr. temp, fatigue

Yellow/Red Flags

______ include:

• pain decr. with sleeping on involved side

• no difficulty sleeping

• shoulder pain is not eased by rest

• insidious onset and pain cant be reproduced

• systemic s/sx

Upper Crossed Syndrome

_____ is when pecs/upper traps/levator scap muscles are tight and deep neck flexors and scap stabilizers are weak

shoulder elevation

if _______ is not achievable due to incr. kyphosis or poor posture, individual will use lower thoracic and lumbar spine to elevate arms

Scapulohumeral Rhythm

Motions to watch for regarding ___________:

• tipping

• winging

• dumping

• shrugging

Dumping

_____ is the lack of eccentric control of the lower traps and SA as the scap comes down from elevated position

Shrug Sign

______ is when there is a torn RTC and the patient cannot elevate their arm

Scapular Winging

_____ is with weak SA + Lower Trap, tight Pecs, tight RTC mms

infraspinatus, teres minor, winging

In IR, the_____ and _____ will pull scap with them and cause ______ → posterior capsule is tight

Scapular Anterior Tilt

_________ is from tight pec minor, tight biceps, weak middle/lower traps, and weak SA

Force Coupling

_______ in the shoulder involves Upper and Lower traps working with SA to create scapular upward rotation

Scapular Downward Rotation

_____ involves weak Upper/Lower traps/SA with tight Levator/Rhomboids/Pec Minor

Upper Limb Tension Test, median

______ (ULTT1 or UTTLA) look at the ______ nerve with:

• shoulder depression/abd

• elbow extension

• forearm supination

• wrist extension

• finger extension

• contralateral cervical SB

Upper Limb Tension Test, ulnar

_______ stretches the _____ nerve with:

• shoulder depression/abd

• elbow flexion

• forearm pronation

• wrist extension/radial deviation

• finger extension

• shoulder ER

• contralateral cervical SB

Upper Limb Tension Test, radial

_______ stretches the ______ nerve with:

• shoulder depression/abd

• elbow extension

• wrist extension/ulnar deviation

• finger flexion

• shoulder IR

• contralateral cervical SB

active

During _____ motion we are assessing any change in symptoms, neuromuscular control, and looking for any compensations to achieve full ROM

resisted

during _____ motion we are looking at myotomes, neuromuscular control and integrity, changes in symptoms, and any differences b/w sides

passive

during ______ motion, we are assessing end feel, change in symptoms, and differences b/w sides

Impingement Syndrome (SAIS)

_____ is either:

• mechanical compression of structures in subacromial space (usually supraspinatus)

• degeneration of tenon and/or bursae secondary to overuse and aging

roof

the _____ of the subacromial space is:

• inf. acromion surface

• coracoacromial ligament

• coracoid process

• AC jt

floor

the _____ of the subacromial space is:

• greater tuberosity

• humeral head

subacromial space

the ___________ contains the supraspinatus, subacromial bursa, long head of biceps, and joint capsule

One, 25

Stage ___ of Neer’s classification is edema/hemorrhage of bursa and cuff in people less than ______

fibrosis, tendonitis

Stage Two of Neer’s classification is _____ and _____ of the cuff or bursa in 25-40 y.o.

Three, partial/full tears, bone spurs

Stage ____ of Neer’s classification involves ____/_______ _____ of the rotator cuff and ______ in those over 40 y.o.

direct compression

Primary SAIS is _________ of RTC and biceps bursa and the cause is either intrinsic or extrinsic

GH instability, Glenoid labral tear

Secondary SAIS is caused by another pathology like _______ or ______

age, AC joint, bicep tendinitis, dyskinesias

Primary Impingement involves ______ (>50yo.), degenerative changes, DJD of ______, bursitis/tendinitis/tendinosis, _________, and scap ______

30, repetitive OH, labrum, cuff

Secondary Impingement involves those <____yo., experiencing ant/anterolateral pain especially with _______ use → issue with static stabilizers (capsule/_____) while dynamic stabilizers (____) are weak and fatigued

Intrinsic Causes of SAIS

_______ = “Within the tendon”

• degeneration or inflammation of tendon/bursa

  • overuse from stress on tissue overtime

  • age related like vascular or metabolic changes

• weak motor control of RTC leads to disruption of force couple of deltoid with ER/IR

  • from overuse, aging, bad ST jt kinematics, poor posture

humeral head

If the motor control of the RTC is weak then the deltoid increases ________ superior translation during shoulder elevation and ER/IR

Scapular muscles

Extrinsic Causes of SAIS: Weakness of motor control issues of the _______ can cause tendon breakdown, instability of ST articulation, faulty GH kinematics, poor posture

Postural dysfunctions

Extrinsic Causes of SAIS: _______ in the C spine and T spine create issues in kinematics of different areas of the spine and scapula working together

Posterior Capsule Tightness

_______ involves increased humeral head sup/ant translation and causes changes in GH + scapular kinematics → increased infra tone

• inf. post. glide would help shoulder get to full elevation

Posterior Shoulder Tightness

_____ is usually measured in supine and passive IR

• stop just before ant lift of shoulder from table → scap substitution

• compare bilaterally

scaps, 94

With horizontal ADD with scap retraction, the pt is supine and retracts their _____ and horizontally ADD their arm with a normal value of ___ deg

Altered Kinematics

Extrinsic causes of SAIS: ______ like scap dyskinesis and humeral dyskinesis can be related to reduced subacromial space

Scapular Dyskinesia

_____ is decreased protraction, ER, and upward rotation during GH elevation

Humeral Dyskinesia

_______ is increased ant. and sup. humeral head translation during GH elevation

Acromial Morphology

Extrinsic causes of SAIS: ________ is related to the bony changes of the acromion → 3 types (flat, smooth, hooked)

RC tears, SAIS

Acromial Angle (b/w scap spine and acromion) is associated with ______ and ______

OS Acromiale

______ is the unfused distal epiphysis

tendons, AC joint, bursae

Overtime, ______ and the _____ degenerate and ______ thicken

full thickness, age

Older patients are more likely to have _______ RC tears so it is important to consider _____ when looking at SAIS

GH instability, labral tears

Younger pts are more likely to have _____ or _______ and may require surgery

overhead, insidious, local, C5-C6

SAIS medical history:

• associated with sports/work activities that are repeatedly _____

• _____/slow onset of symptoms

• pain with activity or provocative positions

• pain = ______ but can refer to _______ dermatomes

local, sharp, limited

SAIS Examination:

• pain = _______ and possibly at C5,6 dermatome

• pain = _____ with provocative mov’ts (OH, cross body, behind back)

• TTP at RC tendons at muscle belly and insertion

• AROM and PROM are ______ d/t p! with ROM, acute edema, or length of symptoms

• Painful Arc

Painful Arc, SAIS, RC tear, AC jt, SAIS, RC tears

_____ occurs during elevation of arm

• p! + sx @ 60-120 deg = ______ and _____

• p! + sx @ 160/170-180 deg = _____ or _____ or _____

resisted

SAIS will have pain with _______ ABD + ER and posture will be fwd head, T spine FL, and scap

decreases, impingement

When a lidocaine injection into the subacromial area ______Sx it is a sign of ______