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Questions and Answers
What is the difference in ROM between female and male individuals?
What is the characteristic of humeral retroversion in terms of arm position?
What is the end feel for asymptomatic or normal shoulder in internal rotation at 90 degrees?
What is the sequence of pain and resistance in an acute shoulder condition?
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What is the typical range of the symptomatic arc in chronic subdeltoid bursitis?
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What is the normal range of the behind back reach test?
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What is the normal range of the cross body reach test?
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What is the normal range of the behind neck reach test?
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What is the primary importance of knowing MMT in shoulder evaluation?
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What is the difference in ROM between the dominant and non-dominant arm in terms of internal rotation and external rotation?
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Study Notes
Sternoclavicular Joint
- The sternoclavicular joint is the only skeletal articulation between the upper extremity and the axial skeleton.
- It is a synovial stellar joint, with articular surfaces that lack congruity.
- The joint has a disc that completely separates the joint and attaches to the cartilage of the 1st rib and the capsule.
- The capsule is very lax, allowing for mobility, and ligaments are strong, providing stability.
Clavicle
- The clavicle is shaped like an italic 'f' and acts as a strut to the upper extremity, resisting compressive forces.
- The medial portion of the clavicle moves the least, while the main function of the clavicle is stability.
Scapula
- The scapula is a thin, flat triangular shape that provides a concave surface, allowing it to glide easily over the convex thorax and ribs.
- The scapula's functions include:
- Increasing the positions available for the hand in space by varying the original position of the proximal humerus.
- Providing stability for the upper extremity during functional activities of the hand.
Scapular Articulations
- There are four joints that make up the scapular articulations: sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral.
- All of these joints work together to provide simultaneous mobility and stability.
Acromioclavicular Joint
- The acromioclavicular joint is a synovial gliding joint with a lax capsule and strong ligamentous support.
- The joint allows the scapula to glide and the clavicle to rotate.
- The joint moves in a way that allows for 35 degrees of elevation and 45-50 degrees of rotation during full overhead elevation.
Scapulohumeral Rhythm
- The scapulohumeral rhythm is a concept that describes the coordinated movement of the scapula and humerus during arm elevation.
- The rhythm is essential for maintaining the orientation of the glenoid fossa with the humeral head to prevent impingement and shear forces.
- The scapula and humerus move in a 2:1 ratio, with the scapula contributing to about 60 degrees of elevation and the humerus contributing to about 120 degrees of elevation.
Rotator Cuff
- The rotator cuff is a group of muscles that surround the glenohumeral joint and provide dynamic stability.
- The muscles of the rotator cuff include the supraspinatus, infraspinatus, teres minor, and subscapularis.
- The rotator cuff works together to generate a force couple that depresses the humeral head and maintains the humeral head in the glenoid fossa.
Instability
- Instability can be classified into two categories: TUBS (Traumatic, Unilateral, Bankart, Surgery) and AMBRI (Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior Capsular Shift).
- The direction of instability can be anterior, posterior, inferior, or multidirectional.
- The Bankart lesion is a common pathology associated with instability, where the periosteum and capsule of the IGHL/anterior labrum complex detach from the scapular neck and adhere to the overlying subscapularis tendon.
Labral Lesions
- Labral lesions are tears or detachments of the glenoid labrum, which can be classified into four types: Type 1 (degenerative/shredded), Type 2 (superior separation), Type 3 (bucket handle tear), and Type 4 (complete separation of the labrum and biceps tendon).
- The MOI of labral lesions is often related to throwing or falling, and the prevalence of labral lesions increases with age.
RTC Pathology
- Rotator cuff pathology is a common occurrence, especially in older adults.
- The pathology can be classified into three stages: tendinitis, partial tears, and full-thickness tears.
- The natural degenerative tendon change as we age, leading to an increased risk of rotator cuff tears.
Adhesive Capsulitis
- Adhesive capsulitis, also known as frozen shoulder, is a condition characterized by spontaneous onset of pain and gradual loss of active and passive shoulder motion.
- The pathology involves irritation of the GH synovium, chronic capsular inflammation, and capsular fibrosis and perivascular infiltration of adhesions into the lax folds of the anterior and inferior capsule.
- The treatment for adhesive capsulitis is often difficult and may involve a combination of physical therapy, steroid injections, and surgery.
GH Osteoarthritis
- GH osteoarthritis is a condition characterized by the loss of joint space, osteophytes, subchondral sclerosis, and subchondral cysts.
- The severity of GH osteoarthritis can be classified using the Kellgren-Lawrence scale or the Weinstein scale.
- The treatment for GH osteoarthritis often involves a combination of physical therapy, pain management, and surgery.### Shldr Pain Decision
- Tissue irritability guides intensity of physical stress
- Impairment type-irritability level also guides intensity of intervention tactics
Imaging Limitations
- MRI findings were most equally frequent on uninvolved side in pts with unilateral shoulder pain
- MRI can accurately identify tissue pathology, but cannot discriminate whether the pathoanatomy is associated with specific clinical presentation or complaint
Shldr Pain Mapping
- Pain on palpation is sensitive but not very specific
- Injection of hypertonic saline into healthy AC joint and SA space
Patient History and Diagnostic Studies
- Subjective hx: past med hx, systems review, previous related injuries, fam hx
- Diagnostic studies: radiographs, arthrography, MRI/CT scan, EMG/NCV
- Pain above clavicular level indicates ACJ involvement or cervicothoracic contribution to problem
Shldr Specific Red Flags
- Severe and/or persistent pain unrelieved by rest or aggravated by exam, activity, or exertion
- Soft tissue mass on palpation
- Absence of sleep disturbance
- Systemic illness/constitutional sx's
- Pleuritic sx's
Differential Dx
- Unlikely causes to rule out: spleen, heart, gallbladder, or lung involvement
- Kehr's sign: referred pain to L shoulder following blunt trauma to spleen
- Myocardial or pericardial disease: heart attack often causes L shoulder pain
- Gallstones: pain referred to R scapula
- Neoplasms: lung cancer
Risk Factors
- Pts with low HDL, high cholesterol, high triglycerides, overweight, pre or diabetic, and HTN are at high risk for shldr pain
Yellow Flags
- Slower prog/return: previous shldr hx, disproportionate illness behavior, adverse sociolegal status, long-term absence from work or sport, expectation of passive tx, mood, fear behavior, and coping skill
Factors to Baseline Monitor
- Pain level
- Self-report fxnal and psychosocial status
- Pt satisfaction (monitor only)
Outcome Measurement Tool
- Patient's rating of their overall condition since the previous evaluation
- Single assessment numerical evaluation: how would you rate your shoulder today as a percentage of normal?
Rotational Normals
- Total arc: whats normal? (activity specific, age, sex specific)
- Adaptations: osseous, humeral retroversion, glenoid retroversion, capsular, muscular
End Feels
- Firm capsular or muscular tension for rotations, flexion, extension, add, and horizontal add
- Soft tissue approximation for horizontal add
- Firm capsular/hard bony end feel for abduction
Pain Resistance Sequence
- Sequence of pain on the motion barrier
- P1 before R1: acute
- P1 before R1-2: subacute
- P1 at R-2: chronic
Symptomatic Arc
- Includes pain, clicking, grating, crepitation
- 70-120: chronic subdeltoid bursitis, supraspinatus tendinitis, or upper fiber subscap tendinitis
Functional Reach Tests
- Fxnal Reach Test / Apley Scratch Test
- Behind Back Reach: normal = T5-6
- Cross Body Reach: normal = 15-20cm
- Behind Neck Reach: normal = T1-2
Manual Muscle Testing (MMT)
- Important to know reliability, construct validity, and relevance of each
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Description
Test your knowledge of shoulder joint assessment in physical therapy, including ROM differences, humeral retroversion, and end feel characteristics.