DPT 754 Shoulder pathology and assessment 1

Resting position of glenohumeral joint (abd and horizontal abd)

40-55* abduction

30* horizontal abduction

Close packed position of glenohumeral joint (2)

Full abduction

Lateral rotation

Capsular pattern of glenohumeral joint (3)

External rotation

Abduction

Internal rotation

Superior glenohumeral ligament limits this motion:

Shoulder adduction

Middle glenohumeral ligament limits this motion:

45* shoulder abduction

Axillary pouch of inferior glenohumeral ligament limits this motion:

90* abduction and neutral rotation

Posterior band of inferior glenohumeral ligament limits this motion:

90* abduction and internal rotation

Anterior band of inferior glenohumeral ligament limits this motion:

90* abduction and external rotation

Which side of the shoulder (anterior vs posterior) is more stable? Why?

Posterior side of shoulder more stable d/t scapula and rotator cuff

AC joint resting position

Arm by side

AC joint close packed position

90* shoulder abduction

AC joint capsular pattern

Pain at extremes of motion, esp horizontal add and full elevation

SC joint resting position

Arm at side

SC joint close packed position

Full elevation (and protraction)

SC joint capsular pattern

Pain at extremes of ROM, esp horizontal add and elevation

Which joints enable movement of humerus at GH joint? (2)

AC joint

SC joint

Define sub-acromial pain syndrome (aka impingement syndrome)

Pathological compression of rotator cuff against anterior structures of coracoacromial arch

Tissues that may be implicated in sub-acromial pain syndrome (2)

Supraspinatus tendon

Subacromial bursa

Rotator cuff pathology causes humeral head to shift in what direction?

Upwards

Methods of classifying impingement syndrome (just names) (3)

Neer impingement

Primary vs secondary

Posterior (internal)

Glenohumeral painful arc occurs between this range of shoulder abduction:

From about 45-60 to 120*

Acromioclavicular painful arc occurs between this range of shoulder abduction:

From 170 to 180

Signs of Neer impingement stage 1 pathology (3)

Edema and inflammation

Pt under age 25yo

Painful arc b/w 60-120*

Signs of Neer impingement stage 2 pathology (2)

Fibrosis and tendinitis

Pt aged 25-40yo

Signs of Neer impingement stage 3 pathology (2)

Bone spurs and tendon ruptures

Pt typically 40-60yo

Signs of Neer impingement stage 4 (2)

Rotator cuff tear arthropathy

Pt typically over 60yo

Structures most commonly involved in primary/secondary impingement (4)

Supraspinatus tendon

Anterior infraspinatus tendon

Bicipital tendon

Subacromial bursa

Signs of primary impingement syndrome (2)

Mechanical obstructions of RC tendons under CA arch

Pt usually older than 35-40yo

Signs of secondary impingement syndrome (2)

Relative decrease in subacromial space d/t another condition

May result from GH or ST joint instability

Usually younger patients (late teens - early 20s)

Signs of posterior (internal) impingement syndrome (2)

Occurs in overhead throwing athletes

Late cocking/early acceleration phase

Which type of impingement syndrome can be relieved by anterior -> posterior pressure?

Posterior (internal) impingement

Functions of scapulothoracic (ST) joint (2)

Orients glenoid fossa for optimal contact w humeral head

Stable base for rotator cuff

Is the ST joint a true joint?

No

Muscles that move the scapula (6)

Trapezius

Rhomboids

Serratus anterior

Levator scapula

Pec minor

Lat dorsi

Muscle force couple imbalances often seen in pts w impingement syndrome (3)

Decreased serratus anterior firing

Delay in middle and lower traps

Dominance in upper traps and levator scapula

Type I Kibler scapular dysfunction results in what scapular compensation?

Tipping of inferior angle

Type II Kibler scapular dysfunction results in what scapular compensation?

Winging of the medial border

Type III Kibler scapular dysfunction results in what scapular compensation?

Shoulder shrug of superior border

Type IV Kibler scapular dysfunction results in what scapular compensation?

Rotary winging during shoulder abduction

Components of SICK scapula (4)

Scapular malposition

Inferior medial border prominence

Coracoid pain and malposition

DysKinesisa of scapular movements

SICK scapula often seen in what population?

Throwers

SICK scapula often causes tightness in which areas? (2)

Pec minor

Posteroinferior capsular tightness w/GH joint IR deficiency

Causes of scapular dyskinesia (4)

Weakness of traps, serratus anterior, scap stabilizers

Loss of scap suspensory mechanism

Winging 2* to instability or pain

Brachial plexus injury

Treatment for impingement syndrome (general)

Address the impairments (ex. posture, muscles, ROM, overuse, ergonomics, etc)

Prevalence of rotator cuff tears in asymptomatic people (not elderly)

13-34%

Prevalence of rotator cuff tears in asymptomatic people ages 60-80yo

51-54%

What structure most commonly involved in rotator cuff tears?

Supraspinatus tendon

Common causes of rotator cuff tears in OH throwing athletes (2)

Impingement

Changes in tendon and muscles

Common cause of rotator cuff tear in elderly

Arthritic changes in AC joint lead to cuff tear

Which type of acromion shape (flat, curved, hooked, or convex) most commonly has RTC tears?

Hooked acromion (Type III)

It's theorized that acromial hooks are actually...

Traction spurs (bone spurs) that develop d/t overuse

Name one ligament associated w RTC tears, esp in OH athletes

Coracoacromial ligament

Causes of humeral head upward rotation (2)

Lack of space in glenoid

Repetitive motions

Classification for RTC tear based on time frame

Acute: Caused by direct trauma

Chronic: Caused by aging

Classification for RTC tear based on size

Small (1cm)

Medium (1-3cm)

Large (3-5cm)

Massive (5+cm)

How do partial thickness RTC tears cause the "zipper effect"?

Tendon scar tissue cannot handle stress of shoulder, keeps ripping over time

In what shoulder position will the RTC receive the most blood? Least blood?

Most: Shoulder abducted

Least: Shoulder adduction, causing "wringing out" phenomenon

Is RTC tendinitis/tendinosis a primary or secondary inflammatory response?

Secondary inflammatory response

Which is more chronic in nature, tendinitis or tendinosis?

Tendinosis

Predictive signs of RTC tear (4)

Supraspinatus weakness

ER weakness

Impingement sign

+Drop arm sign

Symptom of abrasion sign

Painful, audible crepitus at 90* abduction

When is it appropriate to repair the RTC via surgery (instead of rehab?)

If it won't heal via conservative rehab