Shoulder I

Patient Reported Measures

Quick Disability of Arm, Shoulder and Hand (QDASH)

American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)

Penn Shoulder Scale (PSS)

Glenoid labrum

fibrocartilaginous, connective tissue

Key MOI for Anterior Instability / Dislocation often including Bankart Lesion

Arm in ABD + ER, contact

Key MOI for Posterior Instability

Axial load in flexion/IR; seizure

Key MOI for SLAP tear

Overhead deceleration, FOOSH, traction

Key MOI for Bankart/Labral Tear

anterior dislocation

Key MOI for Traumatic RC tear

Traction/eccentric force, FOOSH (>40 y/o)

Key MOI for AC Joint Sprain

Direct blow to shoulder tip, FOOSH in adduction

Primary Complaint for Anterior Instability / Dislocation often including Bankart Lesion

Apprehension, overhead/ER, “clunk”

Primary Complaint for Posterior Instability

Pain with cross-body loading, pain pushing

Primary Complaint for SLAP tear

Deep joint pain, catching, dead arm in throwers

Primary complaint for Bankart/Labral tear

Instability, apprehension

Primary complaint for Traumatic RC tear

acute severe weakness, lateral arm pain, night pain

Primary Complaint for AC joint sprain

Superior shoulder pain, step deformity (Type III+)

Key Test and Signs for Anterior Instability / Dislocation often including Bankart Lesion

Apprehension + relocation tests; imaging shows Hill-Sachs/Bankart

Key Tests and Signs for Posterior Instability

Posterior apprehension/jerk test; CT/MRI for reverse Hill-Sachs

Key Test and Signs for SLAP tear

Biceps load II, O'Brien's; MRI arthrogram gold standard

Key Test and Signs for Bankart/Labral Tear

Instability cluster; often found with anterior dislocation on MRI

Key Test and Signs for Traumatic RC Tear

Lag signs, drop arm; MRI/US confirms full-thickness tear

Key Test and Signs for AC Joint Sprain

Palpation, cross-body adduction; stress X-ray for grading

What could be indicated during examination when presented with a chronic problem or gradual onset?

Sub-acromial (cuff/labrum)

Hypermobility (instability)

Hypomobility (capsular)

Neurological assessment

What could be indicated during examination when presented with post-operative/acute trauma?

Limited mobility and strength testing

Neurovascular status

Does a higher or lower score indicate normal function/no disability in the QDASH?

lower - 0 indicates no disability

Does a higher or lower score indicate normal function/no disability in the ASES?

higher - 100 indicates normal function

Does a higher or lower score indicate normal function/no disability in the PSS?

higher - 100 indicates normal function

Penn Shoulder Scale (PSS)

functional questionnaire for the shoulder specifically

American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES)

shoulder specific questionnaire

Quick Disability of Arm Shoulder and Hand Questionnaire (QDASH)

regional measure for the UE

Muscle Classifications relating to pathomechanics

Axiohumeral

Axioscapular

Scapulohumeral

What does excessive glenoid version lead to?

dislocations

Total depth of the glenoid fossa with labrum

4 mm

What are the anterior ligamentous stabilizers of the shoulder?

Inferior glenohumeral ligament (IGHL)

Middle glenohumeral ligament (MGHL)

Superior glenohumeral ligament (SGHL)

Main ligament that tears in dislocations?

IGHL

When is the IGHL the main stabilizer?

>90 degrees abduction

When is the MGHL the main stabilizer?

< 90 degrees abduction

When is the SGHL the main stabilizer?

< 45 degree abduction

Posterior stabilizers with arm forward flexed and horizontally adducted

Posterior capsule

SGHL and MGHL

Capsular ligaments

non contractile units that primarily stabilize the joints at extremes of motion tissue

SGHL

resists inferior translation (Sulcus test)

MGHL

resists anterior translation with arm at side (Anterior Load and Shift)

IGHL

resists anterior translation with arm abducted (Apprehension, Relocaiton)

What creates the hammock?

Anterior and posterior band

Where does most trauma occur between on a clock?

3:00 to 6:00

Anterior shape of glenoid labrum

wedge shaped

Posterior shape of glenoid labrum

cord-like

Which portion of the labrum is thicker and more firmly attached?

inferior

Removal of labrum?

decreases force necessary to dislocate by 20%

Bankart lesion

detachment of labrum and/or capsule from glenoid associated with traumatic anterior dislocation (4-6 O’clock)

SLAP Lesion

detachment of labrum from glenoid associated with overhead activities (10-12 O’clock) and cuff/bicep injuries

Which type of capsulolabral injury is most associated with anterior dislocation?

Bankart lesion

Which type of capsulolabral tear is common in the pro-rugby population?

Posterior labral tear

Bony Bankart

glenoid rim fracture associated with a bankart lesion

Axiohumeral Musculature

pectoralis major and minor

latissimus dorsi

Axioscapular musculature

trapezius

rhomboids

serratus anterior

levator scapulae

Scapulohumeral musculature

supraspinatus

infraspinatus

teres minor and major

subscapularis

deltoid

What are the axiohumeral shoulder muscles for?

power

What are the axioscapular shoulder muscles for?

posture and proximal control

What are the scapulohumeral shoulder muscles for?

centering for mobility

What does increased compression cause at the glenohumeral joint?

increases the force necessary to dislocate the joint

What two muscles can lead to impingement of the biceps?

teres major and latissimus dorsi

Spinal accessory nerve innervates?

trapezius

Dorsal scapular nerve innervates?

levator scapulae and rhomboids

Function of serratus anterior?

Protract, upwardly, posteriorly, and externally rotate the scapula

Long Thoracic nerve innervates?

serratus anterior

Long thoracic nerve palsy leads to"?

scapula displaces posterior off thorax

Nerve roots for long thoracic nerve?

C5-8

Most injured scapulohumeral muscles

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

Biceps/Triceps

Deltoid

Force couple

two opposing forces acting on same object to create synergistic rotation

Scapular force couples of the shoulder

Lower, upper trap

Serratus anterior

Glenohumeral force couple

Deltoid

Rotator cuff

Traumatic shoulder injuries

Glenohumeral instability

AC Sprains/Separations

Microtraumatic Shoulder injuries

Labral tear - SLAP/Bankart Tears

Rotator cuff tears

Why is a sternoclavicular joint posterior dislocation considered life-threatening?

Hard to swallow, hoarse when speaking - clavicle pushing into the trachea

Which types of AC Sprains are considered non-operative?

Type 1 and 2

Anterior shoulder dislocations

fall on the outstretched hand (abduction and external rotation) resulting in overloading of anterior capsular restraints and disruption of IGHL and Bankart lesion

What factors are strongly associated with increased likelihood of recurrent anterior instability following a primary traumatic anterior shoulder dislocation?

Ages between 14 and 40, male sex, open epiphysis, generalized hypermobility

What factor is strongly associated with decreased likelihood of recurrent instability following a primary anterior shoulder dislocation?

presence of a greater tuberosity fracture

Traumatic posterior dislocation

Arm positioned in forward flexion, internal rotation, and horizontal adduction with an axial load or heavy loads anterior to body

What populations may present with traumatic posterior dislocation due to forceful internal rotation?

Seizure and electrical shock patients, lineman in football

Microtraumatic Posterior Dislocation

repetitive axial loading on forward flexed arm accepting loads

Inferior Dislocation (Luxatio Erecta)

high energy forcing arm into hyperabduction tearing the inferior capsule with humeral head translating inferiorly and presenting with the arm fixed overhead

What are other conditions associated with dislocations?

Labral tears - Bankart lesion

Cartilage damage

Bone lesion - Glenoid surface (Bony Bankart lesion) and Humeral head compression fracture (Hills-Sachs Lesion)

Rotator cuff tears

Nerve injuries (axillary nerve most common)

What dermatome should be checked following a dislocation?

C5

Subluxation

did not need help reducing

Dislocation

needed help reducing

Apprehension/Relocation/Surprise Test

Apprehension - abduction and external rotation

Relocation - return to neutral rotation apply posteriorly directed force to anterior shoulder

Surprise - let go of relocation

(+) for Apprehension/Relocation/Surprise Test

provoke symptoms of instability (apprehensive of position)

muscle guarding

face grimace

grab your hand

Anterior-Posterior Load and Shift

place in open packed position (40 degrees abduction and 30 degrees horizontal adduction) in sitting or supine

stabilize clavicle and scapula with arm closest to patient and grasp proximal humeral head with other hand and center it in glenoid

Glide anterior-medial and posterior-lateral to appreciate relative displacement and end-feel compared to opposite side

Which anterior glenohumeral instability test is considered more subjective and has a lower diagnostic accuracy?

Anterior-Posterior Load and Shift

Posterior Apprehension Test

patient supine and arm brought into forward flexion by examiner, simultaneously apply a posterior force with horizontally adducting and internally rotating the arm

(+) Posterior Apprehension Test

patient apprehension to placing arm in the position, may appreciate a subluxation or click with maneuver or during return toward starting position

Jerk Test

posteriorly directed force applied while horizontally adducting the arm then horizontally abducting arm

(+) Jerk Test

noticeable jerk, apprehension, or guarding occurs

Posterior Glenohumeral Instability Tests

Jerk test

Posterior Apprehension Test

Anterior Glenohumeral Instability Tests

Apprehension/Relocation/Surprise Test

Anterior-Posterior Load and Shift

What are the 6 factors for the Predict Recurrent Instability Shoulder (PRIS)?

age

dominance

bony

immobilization

SPADI

TSK

What does the PRIS estimate?

risk of recurrence

What are the 6 factors of the NISIS?

age

type of sport

bone loss

arm dominance

sex

type of instability

Non-operative Instability Severity Index Scale (NISIS) predicts?

return to sport with non-operative care

What does a <7/10 points on the NISIS predict about athlete return to sport with conservative intervention for managing shoulder instability events?

likely to do well