Shoulder Hypermobility (Condensed)

treatment of hypermobile shoulder: symptom modulation

anti-inflammatory

gentle ROM w/ available ROM

isometrics

strengthening in protected ranges

treatment of hypermobile shoulder: motor control

ROM and gentle strengthening/stabilization exercises (just prior to end range)

strengthening in positions closer to position of instability

treatment of hypermobile shoulder: functional optimization

strengthening

proprioceptive exercises

closed chain exercises

sports/work specific

AT LEVEL OF PRIOR INSTABILITY OR POSITION OF WORK/SPORT

glenoid center line

~10° posterior to the scapular plane

what causes a misalignment of the glenoid center line and what does that result in?

any amount of anteversion, retroversion, upward/downward rotation can cause misalignment of center line --> decrease in net compressive forces

scapular influence on compressive forces at the GH joint

if scapular mechanics/control are poor --> compressive forces are affected

scapular assistance test procedure

1. Assess symptoms (pain) in unassisted scapular plane elevation

2. Repeat with therapist-assisted upward rotation and

posterior tilt

positive scapular assistance test

reduction of pain (2 or more points on 0 - 10 scale)

when is the stability ratio maximized?

when humeral head is centered on the glenoid

onset of GH instability

traumatic

repetitive microtrauma/overuse

atraumatic - often hyperlaxity

subluxation

dislocates, spontaneous reduction

dislocation

dislocates, needs reduction by medical professional

historical classification of GH instability: TUBS and AMBRI

TUBS: traumatic, unidirectional, bankart lesion, surgical repair required

AMBRI: atraumatic, multidirectional, bilateral, rehab, inferior capsular shift

oversimplification + does not account for overlapping presentations

rule in GH instability

younger (<40) with second peak incidence females>70

males>females

reports of instability/pain/apprehension w/ specific shoulder positions

history of sublux/dislocation

+ apprehension/relocation or hyperabd test

possibly + SLAP lesion tests

generalized joint laxity/hypermobility (atraumatic)

rule out GH instability

no history of sublux or dislocation

- apprehension/relocation

- hyperabd tests

special tests: translational tests

anterior/posterior drawer tests

sulcus sign (0 and 90 degrees)

anterior drawer test procedure

Patient is in supine

Arm is abducted to 70-80 degrees

Slight flexion and ER (resting position)

Stabilize scapula with grip, attempt to put thumb on coracoid

Grasp proximal humerus with other hand

Passively translate anteriorly

positive anterior drawer test

increased translation relative to contralateral side

posterior drawer test procedure

Patient is in supine

Arm is in 90 degrees of abduction

Stabilize scapula with grip, attempt to put thumb on

coracoid

Grasp proximal humerus with other hand

Passively translate humeral head posteriorly (downward pressure)

positive posterior drawer test

increased translation relative to contralateral side

sulcus sign (0 and 90) procedure

Patient is sitting

Sulcus at 0° - Arm at side

Sulcus at 90° - Arm at 90 abduction

Passively translate the humeral head inferiorly

positive sulcus sign

excessive inferior translation

anterior instability rule in

younger (15-29)

high-risk activities

history of trauma (or recurrence)

apprehension and/or pain with arm in abd/ER or overhead

possible report of click or mechanical sxs in shoulder

MOI traumatic anterior instability

forceable ER and horizontal abduction

force on distal arm with shoulder in abd/er, horizontal abd

MOI microtrauma/microinstability anterior instability

overhead occupations and sports

SLAP lesion

anterior microinstability MOI

repetitive OH activity (i.e. throwing athlete)

what does anterior microinstability result in (ROM)?

increased ER

decreased IR

due to anterior laxity, retroversion of humeral shaft, soft tissue contracture of posterior shoulder

anterior microinstability results in what type of impingement and why?

posterior (internal) impingement due to posterior shoulder tightness (soft tissue)

physical exam findings for anterior instability: ROM

p! or apprehension at or near end-range

apprehension with abd/ER

altered scapulohumeral rhythm

physical exam findings for anterior instability: joint mobility

apprehension with anterior glide

physical exam findings for anterior instability: strength

assess ER and IR at 90

scaption

mid trap/low trap

serratus anterior

special test for anterior GH instability

anterior apprehension/relocation

anterior apprehension/relocation test procedure

Patient is supine

Passively bring shoulder to 90 abduction

Slowly bring into ER

CONFIRM POSITIVE APPREHENSION

Return out of ER position

Provide posteriorly directed force to humeral head

Repeat the passive ER assessment

positive anterior apprehension/relocation

apprehension with step 1, that reduces with step 2 (relocation)

posterior GH instability history

younger athletes

contact sports

posterior shoulder pain w/ UE WB or positions of flex and horizontal adduction

MOI posterior GH instability

posterior directed force with shoulder in flex/horizontal add/IR

high % secondary to seizures

reverse bankart lesion

detachment of posterior labrum

kim lesion

tear between the posterior labrum and the glenoid cartilage without complete detachment of labrum

when does a reverse hill-sachs lesion on the humeral head develop?

after posterior shoulder dislocation

common sxs reported for posterior GH instability

vague complaints

muscle weakness

fatigue

pain

possible clicking or popping

infrequently report sensation of instability

physical exam findings for posterior instability: ROM

apprehension with flex, horizontal add, IR, or combo

pain at end ranges

look for scapular dyskinesis

physical exam findings for posterior instability: strength

assess ER, IR (0 and 90), scaption, MT, LT

consider willingness to perform CKC exercises

physical exam findings for posterior instability: palpation

posterior joint line tenderness

special tests for posterior GH instability

posterior drawer

jerk test

kim test

posterior drawer test for posterior GH instability procedure

A posterior load and shift that is performed in supine

Stabilize the shoulder joint with one hand

Other hand provides a medially and posteriorly directed force on the humerus

Assess for excessive posterior translation

grade scale for posterior drawer test for posterior GH instability

Grade I --> less than the glenoid margin

Grade II --> beyond margin / reduces

Grade III --> beyond margin / no spontaneous reduction

jerk test (posterior apprehension) procedure

Patient sitting in the upright position

Place arm in FORWARD FLEXION + ADDUCTION + INTERNAL ROTATION

Examiner applies a posterior-directed force along humerus

positive jerk test

posterior translation of the humeral head and as the arm is brought into extension a painful clunk may be appreciated

• This is the humerus reducing

• Indicative of a posterior labral tear

kim test procedure

Patient in upright sitting position

Shoulder in ABDUCTED + INTERNALLY ROTATED Examiner cups the patient's elbow with one hand and grabs over the patient's bicep with the other.

Apply an axial load to the elbow, and move the arm into HORIZONTAL ADDUCTION while applying a posterior-directed force on the humerus

Causes humerus to posteriorly translate out of the glenoid socket

positive kim test

pain, clunk, or click

beighton scale

to assess hypermobility - >4 indicates hypermobility

management of posterior GH instability

begin non-operatively with strengthening stabilizers and gradually build up axial loading of humerus

if fails, surgical management (soft tissue or bony anatomy)

inferior GH instability history findings

<40

atraumatic

traumatic is very rare - inf directed force on prox arm while in abd

generalized laxity

presents with multi-directional instability

multi-directional instability (MDI)

at least 2 directions

beighton scale >/= 5/9

+ Sulcus sign

physical exam findings inferior GH instability: ROM

apprehension in abd

pain/instability at end ranges

physical exam findings inferior GH instability: strength

assess ER/IR (0,90), scaption, MT, LT

assess willingness to perform CKC

consider assessing core/endurance

special tests for inferior GH instability

hyperabduction test

hyperabduction test procedure

Patient is seated, PT stabilizes the shoulder to prevent

scapulothoracic rotation

PT will then raise arm to end-range GH ABD

Normal range is ~90°

positive hyperabduction test

apprehension OR increased laxity (> 105° abduction)

concomitant pathologies: bony defects

1. Bony Bankart lesion (anterior instability)

2. Hill-Sachs lesion (anterior instability)

3. Reverse Bony Bankart lesion (posterior instability)

4. Reverse Hill-Sachs lesion (posterior instability)

5. Glenoid Bone Loss

6. Bipolar bone loss - the ball (hill-sach) and the socket lose bone

7. Greater Tuberosity fractures

concomitant pathologies: rotator cuff tears

> 40 years old

posterior-superior if trauma MOI

subscap most common

concomitant pathologies: labral

commonly bankart

SLAP lesion

concomitant pathologies: brachial plexus injury

increased risk w/ increased age

more often multiple nerves (axillary almost never)

MOI:

impact --> inf cord

traction --> medial cord

result of vascular injury less common

concomitant pathologies: brachial plexus injury recovery

spontaneous in most

MOI SLAP lesions

often not isolated

FOOSH

repetitive throwing/OH activity

- traction of LHB on superior labrum (forceful eccentric contraction)

- peel back of labrum during ABER

- posterior impingement

SLAP lesions history findings

clicking, popping in shoulder

dead arm sensation

discomfort in OH positions

general weakness

often vague

accompanied by other shoulder pathology

type 1 SLAP lesion

Degenerative fraying of labrum

type 2 SLAP lesion

Degenerative fraying of labrum + detachment of biceps insertion

type 3 SLAP lesion

Bucket- handle tear with intact biceps

type 4 SLAP lesion

Bucket-handle tear with intrasubstance tear of biceps

associated intra-articular lesions with type 1 slap

supraspinatus tears

associated intra-articular lesions with type 2 slap

< 40 years old --> Bankart lesions

> 40 years old --> supraspinatus tears and GHOA

associated intra-articular lesions with type 3 and 4 slap

bankart lesions

physical exam findings SLAP lesions

+ SLAP lesion tests

focal tenderness of LHB tendon

restricted IR and excessive ER of GH joint

may have unilateral ST dysfunction

special tests for SLAP lesions

anterior slide test

biceps load test (I, II)

compression-rotation test

active compression test (o'brien's)

crank test

speed or yergason test (biceps)

proposed SLAP clusters

1. passive distraction (i.e. maximal stretch of LHBT) and active compression

2. anterior slide + history of popping or clicking

are SLAP special tests good?

nah - please rely on diagnostic imaging (MRA) to confirm diagnosis

anterior slide test procedure

Examiner provides forward & slightly superior directed force to the elbow

While the patient is asked to push back against that force

positive anterior slide test

pain and / or click in shoulder

biceps load I and II test procedure

UE is placed at end-range ER in 90 (I) and 120 (II) abduction, forearm supinated

Subject contracts biceps against examiner resistance

positive biceps load I and II test

(+) pain with contraction of biceps

(-) no pain; or if pre-existing pain is reduced or eliminated

compression-rotation test procedure

Patient lays supine

Shoulder abducted to 90°, elbow flexed to 90°

Examiner pushes the humerus into the glenoid (axial load)

Examiner then rotates the humerus internally and externally

positive compression-rotation test

catching, popping, snapping sensation

active compression test (o'brien's) procedure

2-part test

Patient standing, flexes shoulder to 90° with full elbow extension

Then adduct 10° and Internally Rotate

Examiner pushes the arm toward the floor while patient resists- This may elicit deep shoulder pain or clicking sensation in GH region

Procedures is then repeated with patient's arm in full supination

positive active compression test

pain or click is reduced with the 2nd part of test

crank test procedure

Passively internally & externally rotate arm in ~160° ABD while applying axial load

Sometimes also called "compression-rotation test" except now in greater amount of abduction

Can do in supine or seated

positive crank test

Pain and/or click are (+) for labral lesion

GIRD

associated often with anterior microinstability

Glenohumeral Internal Rotation Deficit

variation in definition

biomechanical adaptations in GIRD

increased ER --> anterior GHLs lengthened

decreased IR --> posterior capsule and soft tissue contracture

both lead to development of increased humeral retroversion over time

total arc of motion

Is the sum total of ER + IR ROM at 90° abduction

difference of total arc of motion predictive of injury

more than 5 degree difference

anatomical GIRD

normal in OH athletes

loss of IR < 18-20

symmetrical total arc of motion

pathological GIRD

abnormal in OH athletes

loss of IR > 18-20

total arc > 5 degree difference - more aggressive intervention

how to determine non-op vs op care for instability?

PRIS tool

NISIS (<7 low risk, >7 high risk)

operative management

look at slides :)