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Terms in this set (80)
How is the humeral head inherently oriented in the glenoid fossa?
Glenoid has an upward tilt
Inherent retroversion of the femoral head
This allows for some extra stability in the shoulder, but inherently is an unstable joint
What is the static position in neutral of the humeral head and the scapula?
5º of upward tilt
What is the plane of the scapula?
It's about 30-35º anterior to the frontal
We dont usually do things in the straight sagittal or frontal plane. Keeping it in the scapular plane will help keep things from subluxing
About what percent of total movement of the shoulder is happening from the scapula?
When you externally rotate the shoulder the humeral head glides in what direction?
When you dislocate, you are going to dislocate anteriorly 98% of the time
What innervates the subscapularis?
Upper and lower subscapular nerve
What innervates the supraspinatus?
What innervates the teres minor?
What innervates the teres major?
Lower subscapular nerve
What innervates the serratus anterior?
Long thoracic nerve
What innervates the latissimus dorsi?
What is the action of the subscapularis?
Glenohumeral head depressor
Medial rotation of the humerus
What is the action of the supraspinatus?
Abduction, stabilization of glenohumeral joint
What is the action of the infraspinatus?
Extension and external rotation
What is the action of the teres minor?
Extension and external rotation
What is the action of the teres major?
Adducts and internally rotates arm
What is the action of the serratus anterior?
Protracts and rotates scapula and holds it against thoracic wall
What is the action of the latissimus dorsi?
Extends, adducts, and internally rotates humerus
Upward rotation of the shoulder comes from what muscle?
What is unique about the origin and insertion of the levator?
It's origin and insertion can switch off
Winging of the scapula can come from dysfunction of what muscles?
Middle or lower trapezius
What is the plus sign?
Test for winging scapula
Against the wall it'll tell you if you have a problem, but EMG nerve conduction can differentiate
What is the scapular flip sign?
Elbow at 90 and resist ER
If scapula flips off thoracic cage its a trap issue
What are the factors that contribute to static stability of the shoulder?
- HH compressed against inclined glenoid
- glenoid position of slight upward rotation
- supraspinatus of posterior deltoid
- negative intraarticular pressure
What factors contribute to dynamic stability of the rotator cuffs?
- muscle contraction centralizes HH
- contracting RTC develops tension and squeezes HH
- passive RTC tension (inherent tone)
- RTC orientation
- equal and opposite joint reaction and frictional forces
what are the different joint components that make up the entire shoulder joint?
1. glenohumeral joint
2. sternoclavicular joint
3. acromioclavicular joint
4. scapulothoracic (not a true joint)
need ALL these joints to be functioning to get full motion in the shoulder.
absence of any of them you will either substitute or create a pathology
What is Sprengel's deformity?
Congenital elevation of the scapula
what is the definition of impingement syndrome in the shoulder?
impingement of a structure in the supra-humeral space
usually between anterior/inferior 1/3 of the acromion and the greater tuberosity
impingement syndrome in the shoulder typically impinges what muscle(s)?
Usually the rotator cuff (supraspinatus) and/or long head of the biceps tendon
what are the types of shoulder impingement syndrome?
1. primary - AC joint or acromion type
2. secondary - posterior capsule tightness (anterior loose), result of underlying pathology
3. posterior - overhead athlete (cocking phase, elevation and ER)
What is Neer classification?
it is a classification system to figure out treatment for proximal humerus fractures
if someone is over 55, what percentage of them will have cuff tears if they have shoulder pain?
this DOESNT mean you're symptomatic
cuff tear is typically over what age?
impingement is what type of inflammatory pathology?
but remember... tendonitis isn't always impingement
where is the big area of referred pain for the shoulder?
what does the rotator cuff do? (4 things listed on slide)
1. guides humeral head
2. adds dynamic stability
3. ABD, IR, ER
4. fine tune movement
what are the MC causes of rotator cuff tears?
2. repeated microtrauma (overhead athlete or worker)
3. steroid injections
bursal: compression (supraspinatus rubs acromion)
what is a wringing out of cuff injury?
hypovascular portion of supraspinatus tendon
blood flow here decreases with age
what are the different types of tears of the supraspinatus tendon?
1. full thickness - from articulating surface to bursal floor of cuff
2. partial thickness - intrasubstance tears
what are the classifications of rotator cuff tears?
1. small = < 1 cm
2. medium = 1-3 cm
3. large = 3-5 cm
4. massive = > 5 cm
large to massive tears usually indicate poor tissue
> 4 cm tear = high re-tear rate
what imaging is the most sensitive and specific for partial RTC tears?
what imaging is the most sensitive and specific for full thickness RTC tears?
US, but note that MRI improves significantly for full thickness tears to 89 sensitive and 93 specificity
how is open RTC surgery performed?
deltoid split vs turndown
how is mini-open RTC surgery performed?
acromioplasty + open repair
how is arthroscopic RTC surgery performed?
acromioplasty vs (or including) repair
what are the 3 major pathologies of the long head of the biceps?
the long head of the biceps acts as a humeral head _________
what is the attachment site for the long head of the biceps tendon?
the supraglenoid tubercle
inflammation occurs where biceps tendon passes through bicipital groove over the head of the humerus
sheath of the tendon is an extension of the synovial lining of the rotator cuff
what are the 3 types of biceps instability?
1. superior subluxation due to loss of coraco-humeral ligament
2. unstable at entrance to bicipital groove (transverse humeral ligament)
3. post non-union or malunion of lesser tuberosity fractures
often assoc w loss of integrity of subscapularis tendon
can sublux in cocking phase of throw or forceful IR
does a full thickness tear of the long head of the biceps hurt?
no (less pain than partial or no pain at all)
what is the typical mechanism that causes full thickness tear of long head of biceps?
FOOSH or forceful supination movement
how do you treat biceps rupture?
you can live a very functional life as long as you have your supinator muscle
how would a patient present with calcific tendonitis of the supraspinatus?
shoulder is on fire
cant do anything
if you do nothing at all the pain usually resolves in 4-6 weeks
what is the most common way that a shoulder dislocates?
96% through traumatic events
98% dislocate anterior (anterior/inferior)
Where does a bankart lesion occur?
Lower part of labrum (anterior inferior labral tear)
where does a hill-sashs lesions occur
bone bruise - posterior humerus
if you are under 21 and you dislocate your shoulder, what is the percent chance you will dislocate again?
what is AMBRI?
Atraumatic multidirectional instability that is commonly bilateral and is often successfully treated with rehabilitation and occasionally an inferior capsular shift (surgery)
what is TUBS?
Traumatic unilateral dislocations with a Bankart lesion that can be successfully treated with surgery
what are the most common clinical exams used to labral lesions/instability?
active compression test (O'Briens)
load and shift
clunk labral test
what is the MC nerve injury in the shoulder and usually from anterior dislocation?
what are SLAP lesions?
anterior to posterior
what is the etiology of SLAP lesions?
long head of biceps attaches to sueprior labrum
humeral head depressor and anterior stabilizer
what is the mechanism of injury of SLAP lesions?
force pushes humeral head over (peel back) or pulls humeral head away from superior labrum
1. repetitive over head lifting
3. sudden grab of an object w pull
4. deceleration phase of pitching
how does a SLAP lesion present?
like impingement with complaints of popping, catching, locking
locking always think potential internal pathology
what are the classifications of SLAP lesions?
type 1 - labrum remains attached, frays superior
type 2 - superior labrum and biceps are detached from glenoid
type 3 - labrum has bucket handle tear w/ intact biceps
type 4 - bucket handle tear that extends into biceps tendon
how are Type I and type III SLAP lesions managed?
type II and type IV are repaired
these usually do not respond to conservative management
what is the best imaging technology for labral tear?
distend joint w fluid
needle guided fluoroscopy (gadolinium)
pt in neutral with AB and ER
what is the mechanism of injury of an AC joint injury?
fall on to a point of the shoulder
What is the Allman-Rockwood Classification for AC joint injury?
how do you treat a type I allman-rockwood?
NSAID, Ice, Rest
can lead to dJD
distal clavicle resection (mumford procedure) GOLD standard
- remove distal .5-2 cm of clavicle preventing impingement
how do you treat a type II allman-rockwood?
disrupted AC ligaments and capsule
widened AC joint space, downward displacement of clavicle
may see step-off deformity
how do you treat a type III allman-rockwood?
rehab only or repair - controversy
complete disruption of AC capsule and CC ligaments
weaver-dunn: take down CA ligament and repair CC ligament with it
what is adhesive capsulitis?
inflammatory AND fibrosing condition
*global motion loss (capsular pattern) - intraarticular volume decreases)
what is capsular pattern?
external rotation more restricted than abduction which is more restricted than internal rotation
pain and pattern think adhesive capsulitis
can take 2-3 mo or up to 12 before you get motion back if ever
what are the physical exam findings for frozen shoulder?
pain over deltoid tuberosity
increased night pain
loss of function
capsular pattern of motion loss
compensatory shrug w attempted elevation
what is stage 1 of adhesive capsulitis?
first 3 months
pain w loss of motion due to pain inhibition (NOT capsule tightness)
hypertrophic vascular synovitis
modalities for pain
what is stage 2 adhesive capsulitis?
progressive loss of motion
hypervascular synovitis, capsular fibroplasia, disorganized collagen
tx: reduce inflammation, minimize capsular adhesions, grade III mobs
what is stage 3 adhesive capsulitis?
global motion loss can be EXTREME
capsular fibrosis and significantly decreased volume
NO NSAIDS OR INJECTIONS - no inflammatory cells present
Grave IV mobs/manips
TERT - total end range time
what is stage 4 adhesive capsulitis?
can take 1-3 years to resolve for some
slow steady recovery of motion
This set is often in folders with...
4. Lumbar Spine
elbow, wrist, hand, GenO
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