AD I Shoulder Study Guide.odt

Narrated Shoulder Pathology Lectures9/8/2023 Shoulder Instability Classification Traumatic  Single force that applies excessive overload to the joint Often damages the labrum and possible capsule Often leads to Bankart lesion (anterior inferior tear of the labrum) Anterior dislocation with excessiv...

Narrated Shoulder Pathology Lectures9/8/2023 Shoulder Instability Classification Traumatic  Single force that applies excessive overload to the joint Often damages the labrum and possible capsule Often leads to Bankart lesion (anterior inferior tear of the labrum) Anterior dislocation with excessive indirect force involving abduction, horizontal abduction and external rotation. Posterior unidirectional instability usually caused by fall on an outstretched hand (FOOSH) Atraumatic  Joint laxity leading to recurrent subluxations (prior to a minor injry that results in dislocation Multidirectional and typically bilateral Can be congenital Primary treatment is rehabilitation to build up stability around the joint If surgery is required, often an inferior capsular shift is recommended Bankart lesions unlikely but not impossible Acquired  Repetitive motion; instability usually in one direction Overstretched capsule: Functional instability Scapular control is usually lacking in these patients Traumatic injury can be the first dislocation this person acquires. Pitchers  constantly in ER, so what happens to anterior and posterior capsule? Instability/Dislocation Etiology Traumatic Overuse, atraumatic Microtrauma Congenital Neuromuscular  Erbs Palsy, CP) Recurrence rate: Young (80-95%), over 40 (10-15%) Frequency Acute Recurrent Direction Anterior (98%) Occur most frequently in young adults I most, head of humerus is levered anteriorly and sits past the coracoid process, anterior capsule may be stretched or torn Posterior (2%) MDI Degree Dislocation Subluxation Micro (transient) Two Types of Labral Tears SLAP  4 types Labrum keeps the head of the humerus in the glenoid, so when a tear occurs, this stability is compromised Bankart  labrum is torn away from the glenoid. Bony bankart  part of glenoid is pulled off Examination Subjective May or may not have history of trauma May hold arm in IR and adduction (if anterior dislocation); sensation of arm slipping when positioned in ER with abduction Subjective feeling of “arm going dead” and “noist” shoulder Muscular spasms Special tests Sulcus sign  MDI PT exam  Joint laxity, apprehension and relocation, crank test, rule out peripheral nerve damage **If you believe someone has a dislocation, probably not a good idea to perform these tests** **If you suspect dislocation, brace them into abduction and neutral rotation to sit the head of the humerus into the glenoid so that it has contact before referring out** Objective findings Positive apprehension when put into extreme rotations May find crepitation or popping May find generalized joint laxity Rule out slap lesion, GH osteoarthritis, impingement syndrome (pain, but negative apprehension test), RTC (pain and weakness, with negative apprehensive test) Instability/Dislocation: Treatment Non-operative Phase one  immobility (brace): 2-6 weeks Brace in neutral rotation and adduction Maximum/moderate/minimal protection phases Goal  strengthen shoulder in all planes Key muscle groups (scapular stabilizers) Start isometrics, dynamic stabilization, plyometrics Activity modification with instability Anterior  avoid ER and abd (bench press, fly, pull downs, pushups) Posterior  avoid IR, horizontal adduction, flexion (fly, psuhup, weight bearing exercises) Inferior  avoid dependent arm, full flexion (shrugs, military press, deadlift) Surgical Treatment Indications Indications Inability to reduce closed reduction Presence of avulsed bone on inferior glenoid margin (leads to future instability) Significantly displaced glenoid fracture involving 1/3 ir more of the articular cartilage Vascular impairment Fracture of the neck of the humerus or displace tuberosity fracture Surgical Procedures Bankart  least invasive because it involves capsule only They take the joint capsule and sew it to the detached glenoid labrum using stitches or bone anchors (this is without having to move the subscapularis tendon) Bristow  Uses the tip of the coracoid as a bony block at the anterior inferior glenoid neck to prevent dislocation Putti-Platt  Based on the idea to tighten the anterior capsule subsequently with loss of ER in order to increase the stability of the shoulder Capsular shift  addresses multiplanar instability They take the inferior and superior aspects of the capsule, and bring it together to decrease the volume of the shoulder joint Thermal shrinkage  More serious side effects; axillary nerve involvement, more recurrent instability and capsular attenuation- not good outcomes Rehab principles for Shoulder Instability Healing tissue should never be overstressed Effects of immobilization must be minimized The patient must fulfill specific criteria to progress Rehab based on current evidence; there is no cookbook Team approach  physician, PT, and pt. Phased Rehab Goals Immediate postop Protect healing capsular tissue Prevent hypomobility Reestablish muscle firing patterns and reenhance joint stability Diminish pain and inflammation During first 4-6 weeks, you may lose strength Gradually increase ROM Submax isometrics in a safe ROM ROM in scaption, rhythmic stabilization to enhance proprioception, RC muscle coactivation, modalities to address pain and inflammation Common Sequencing of Events Overuse  microtrauma  instability  subluxation  impingement  RTC tear Subacromial Impingement Syndrome One of the most common causes of shoulder pain and dysfunction Linked to and accompanies different diagnoses Closely related to RC pathology Especially involves supraspinatus tendon Pt. may c/o  pain with shoulder level or overhead activity, lifting pain when reaching behind back, pain in deltoid region or lateral arm. You will be able to palpate tenderness They may have decreased strength if it has been going on for a while Loss of ROM due to pain and disuse Pain at night and inability to lay on the affected arm Pain with active palm down abduction (don’t have opportunity to clear the tubercle when bringing arm up overhead) **Symptoms can also be indicative of other shoulder pathologies** Subacromial Space Created by  Acromion, coracoacromial ligament (coracoacromial arch), humeral head Structures within  long head of biceps tendon, articular capsule, rotator cuff (supraspinatus tendon), subacromial/ subdeltoid bursa, coracohumeral ligament Space in normal shoulder is 9-10mm Head of humerus normally translates 3mm superiorly during midrange elevation of the shoulder and anterior/posterior and inferior/superior about 4-10mm during end range elevation if all structures are functioning normally Impingement classification Neer  Time/ Chronicity Stage one  edema and hemorrhage are present Typical age: <25 years Course: reversible S/S Treatment: conservative Stage two  Tendinitis and fibrosis Typical age: 25-40 Course: Recurrent pain with activity S/S Treatment: Conservative/ surgical Stage three  Bone spurs, rotator cuff tearing Typical age: >40 Course: Progressive disability S/S Treatment: Acromioplasty and rotator cuff repair Stage four  Longstanding years with arthritis Current  Location/cause Outlet Primary extrinsic impingement Results in soft tissue/boney changes Confined to the subacromial space Typical seen >40 yo Seldom instability Hypertrophic degenerate process to any structures in the space, or structural changes like shape of the acromion which can close off the space, spurring, etc. all leading to increased contact time with the rotator cuff More hypomobile issue Secondary extrinsic impingement Results of scap dyskinesia, RC fatigue Problem with keeping the humeral head centered in the glenoid fossa during arm movement Typical seen 15-35 yo More of a hypermobility issue Non-outlet Posterior internal impingement (glenoid impingement) Contact of undersurface of the RC with posterior/superior labrum and head of the humerus Occurs during forced elevation and internal rotation Can result in progressive pathology of RC and labrum Posterior shoulder pain in the throwing or overhead athletes Stiffness, slow to warmup Factors Related to Impingement Anatomical Acromion Flat  10-17% Curved  most common Hooked  Mistyped secondary spurs Coracoid  Too long Other factors Age  Changes associated with normal aging process Position of arm  Think about force couples Arm in 60-90 degrees of elevation places high demand on rotator cuff to counteract the pull of the deltoid If deltoid overpowers the RC, it can lead to anterior translation of the humeral head because the RC is not depressing as the arm is elevating, taking up space in the subacromial region. Esp. w/ OH activities Postural imbalance, muscle imbalance, scapular dyskinesia Think about the deltoid and the inferior RC muscles. If there is fatigue in the RC muscle, you’ll have greater excursion of the humeral head Weakness in scapular retractors can putt eh scapula in protraction most of the time, narrowing the subacromial space If there is weakness in the serratus and traps, there will be decreased upward rotation, increasing chance for impingement of RC and bicep tendons in the subacromial space Structural asymmetry  Causes problems with length/tension relationship Capsular tightness  Sometimes in the capsule, you can have tightness in one area and hypermobility in another Calcific Tendinitis A buildup of calcium deposits in the tendon, typically the supraspinatus as it is compressed over time Usually treated with NSAIDs and therapy, including iontophoresis and ultrasound Examination Subjective Findings Pain In lateral aspect of upper arm near the deltoid insertion  referred pain Anterior proximal humerus or peri-acromial area Functional loss of shoulder motion Usually see painful arc when you ask them to lift their arm Functional loss due to pain, weakness, stiffness, “catching” when arm is used in flexion and IR position Pain provoked by daily activity Difficulty sleeping on that side Objective examination for Impingement Neurologic screening  to rule out any other pathologies P/AROM  painful arc Scapulohumeral rhythm  force couples and AROM Palpation/observation  May see atrophy, also to reproduce pain Capsular integrity  anterior instability, posterior tightness MMT/flexibility Posture  Forward head, forward shoulders, rounded back. Etc. impacts force couples Special tests  cluster of signs Special tests Hawkins/Kennedy  rotator cuff between greater tuberosity and acromion Painful arc Coracoid impingement Sign  same as Hawkins Kennedy- arm in 10-20 horizontal adduction before rotation Yocum test  Arm on opposite shoulder- raise elbow Neer Sign  rotator cuff against coracoacromial arch Internal rotation resistance strength test (IRRST) (Zaslav Test) Differentiate between internal and external impingement If positive- indicates internal impingement **Cluster of HK, painful arc, infraspinatus test yield best probability (95%) for any degree of impingement syndrome Treatment- Impingement Conservative Pain control  activity modification, medication, modalities Restore scapular stability/ ensure proper muscle and motor function  force couples and scapular stabilizers Restoration of RC strength Avoid heavy weights into flexion and abduction Avoid OH activities until scapular stability has been restored Improve endurance Reverse inflexibility  myofascial/joint scapula and GH Strengthening in the back, stretching the front Restore joint mobilization Posture corrections Patient education to minimize further trauma and correct faulty posture Surgical Correction of instability (secondary) Acromioplasty/decompression (primary) Rotator Cuff Pathologies Rotator Cuff Tendonitis S/S Shoulder ache/fatigue Pain w/ repetitive movement Difficulty raising the arm over 90 degrees (impingement) and lowering (eccentric) Painful arc Supraspinatus tendon is most commonly involved due to where it is in the subacromial space (sits right under the acromion) Diagnosis  Rule out cervical spine/ RTC tear Treatment Conservative  Address perpetuating factors; PT/mechanics Rotator Cuff Tears Onset  Traumatic, overuse Often in individuals over the age of 40 Usually involves supraspinatus and sometimes infraspinatus and teres minor depending on severity Classification Small  <3cm Medium  1-3cm Large  3-5cm Massive  >5cm S/S Small/medium  full PROM and AROM Large  decreased AROM Can be asymptomatic Weakness Classification by location Superior  supraspinatus (most common) Superior/posterior  supraspinatus and infraspinatus Superior/anterior  supraspinatus, rotator interval and subscapularis, and sometimes long head of biceps tendon Examination: Subjective Findings C/o significant weakness and pain during activities, esp abd/ER Pain  upper back, deltoid, shoulder, arm Difficulty sleeping at night Pain with eccentric loading “popping” sensation possible Diagnosis Examination Palpation Tenderness SA bursa/ greater tuberosity ROM Strength Supraspinatus tears Infraspinatus tears Minor tears Subscapularis tears Special Tests Drop arm Empty can Lag signs Lateral jobe Imaging Radiographs MRI Arthrogram Ultrasonogram Objective findings Asymmetry, atrophy in RC muscles or muscles around shoulder joint Tenderness to palpation, particularly at the greater tuberosity Depending on the extent of injury and chronicity, you may find no weakness or profound weakness and loss of P/AROM Go into differential diagnosis and rule out C/S or radiculopathy Treatment Conservative Rest from provocative activities  Work outside painful arc and work on appropriate biomechanics ROM exercises Resistance exercises below 90 Modalities to decrease pain NSAID’s Cortisone (1-2 max) Breaks down tissue so avoid any with full thickness tear **Surgery probably would not be successful for someone over the age of 70 with a chronic tear **Conservative therapy also appropriate in individuals with partial thickness and small tears Operative  failed conservative treatment or full RTC Usually in individuals over the age of 40 Arthroscopic Mini open Open (Cuts through the deltoid) Treatment: Post surgical RTC repair Rehab Treatment for operative Phase 1  maximal protection Goals: Manage pain, swelling, maintain joints prox/distal to surgical site, protect surgical site PROM, a little AAROM, grip strength and other activities that have nothing to do with the surgical site Phase 2/3  moderate/minimal protection Goals: Increase ROM, manage scar, stabilization strength of the area, improve overall fitness, increase strength of surgical site (late in phase), improve overall function (first basic ADLs, then overhead ADLs) Phase 4  Return to work/sport Early ROM Activities Pendulum: Codman’s Exercises PROM (2-6 weeks)  greater motion parameters to structure torn and amount of tension created during surgery Active assisted (4-8 weeks) L bar, towel No towel, stretch behind back for 3 months w/ medium-massive tears Active  Move in scapular plane Joint Mobility Watch- inferior glide (tightens up) Lots of scarring even with arthroscopic surgery Rehab Approaches Type I  small tear, good tissue Sling 7-10 days, AROM 4-5 weeks Type II  Medium-large, good to OK tissue Sling 3 weeks, AROM 6-10 weeks Type III  Massive tear, poor tissue Pillow at 70 degrees 3-5 days, then at 30 degrees for 4-6 weeks, full AROM 6-8 months These are general- slightly on aggressive side except for Type III, follow protocol given Generally resistive exercise of shoulder 8-12 weeks post-op Firs in protected ranges, then overhead Strengthening Start isometrics- muscle setting Grip strength GH head control Static hold (rotator cuff and deltoid) Increase rhythmic stabilization  work above and below impingement area Once AROM is possible, gravity minimized, then start against gravity Watch strength with arthroscopic repair, even less than mini repair (use more anchors) Isotonic  week 8 (light) Biofeedback Pull in scapular stabilizers Inhibit upper trap (avoid shoulder shrug sign) Need to strengthen posterior cuff ER/IR ratio Bicep Tendon (LHBT): Pathologies Inflammatory/Degenerative  Usually associated with subacromial impingement and repetitive overhead activities, such as in athletes, leading to a tendonitis or tendinosis and eventually a rupture. Instability  varies from subluxation to dislocation and is associated with a RTC tear Long head of the biceps is an anterior stabilizer and humeral head depressor, so if you have dislocation or subluxation, leading to instability, think about the impact it has on the shoulder joint SLAP Lesion (labral/LHBT)  superior labrum from anterior to posterior FOOSH, traction mechanism (catching a falling heavy object), peel back (abducted and maximally ER UE leading to gradual acute detachment from the glenoid) Long head of biceps attaches to superior labrum so if you have a SLAP tear, it can be affected Can be classified according to signs/symptoms Can be classified by type and ranges from fraying of labrum to fully tearing the labrum and avulsing the bicep tendon SLAP Lesion Subjective History of trauma or overuse C/o pain and/or instability with overhead activities with symptoms of “noise” (clicking, catching, etc.) Objective Positive biceps load test, positive clunk test, speed, jobe relocation, positive active compression (O’Brien’s) test Usually found in combo with either impingement or instability Biceps Tendon Disorders: Tendinitis/Tear History Examination  pinpoint tenderness in bicipital groove, best localized w/ humerus in 10 degrees IR placing tendon anterior (tendinitis) Subjective Pain: Diffuse/vague around anterior shoulder Aggravated by resisted elbow flexion Loss of shoulder ROM Palpation Not sensitive enough for tears Point TTP over bicipital groove ROM  pain w/ resistance, painful arc Speeds Yergason AC Joint Sprain/Separation History Mechanism of injury Fall onto tip of shoulder FOOSH Repetitive overhead activity Degree  classified as 1 of 6 types depending on severity More common in men than women and relatively young as opposed to elderly Classification of AC Trauma Type I  reestablish full ROM and strength Type II  requires 6 weeks to heal, pt. will be in a sling, treatment will be for pain relief Type III  Can be treated conservatively or surgically, there is complete tearing of the AC ligaments and of the deltoid and trapezius attachments. Sling for a few weeks, followed by PT Type IV and V  Rare and require surgical repair for type IV AC Joint Sprain/Separation Examination “step” or “piano key” Type III and greater Tenderness at joint Pain and limited AROM abd and horizontal adduction PROM  same Pain with resisted ER and flexion Pain with traction or compression Cluster of 2+ signs Excessive joint play Treatment Non-Operative (type 1-2) Immobilization (1-4 weeks) Rest and activity modification NSAIDs AROM and strengthening (Isometrics) Scapular stabilization Avoid weightlifting/contact sports 8-12 weeks Operative AC repairs Coracoclavicular repair Distal clavicle excisison Dynamic muscle transfer One of the complications is distal clavicle osteolysis (aka weightlifters shoulder) Can occur without separation Repetitive microtrauma Adhesive Capsulitis, Bursitis, and Factures of the Shoulder Joint Adhesive Capsulitis/Frozen Shoulder Pathogenesis Primary  Idiopathic Patient comes in with all the symptoms, but pt. doesn’t know how it started or when it started Secondary After trauma or known surgical event Could be from diabetes, hypo or hyperthyroidism, etc., trauma, post-surgery Inflammatory and fibrotic (may be due to increase cytokines) Rotator cuff interval is usually involved Stages: Either 1-3 or 1-4 stages 1  mild discomfort and restriction 2  motion restricted, painful, synovitis: Freezing phase 3  adhesions are significant, loss of inferior axillary fold 4  No more synovitis, ROM severely restricted Thawing phase  resolution, slow recovery of motion Three stages 1  freeing/ painful stage (includes both stage 1 and 2 above 2  Adhesive/restrictive stage 3  resolution stage S/S Consensus on clinical identifiers for stage 1 Pain  diffuse, deep ache Night Rapid movement Lying on affected side Global loss of PROM and AROM w. ERP (capsular pattern) Progressive difficulties with ADL Examination Objective finding Scap dyskinesia May have point tenderness over bicep groove ROM loss capsular pattern Neurologic tests are negative Pain at end range of resisted shoulder motion (not typically at midrange) Treatment Early  reduce inflammation, relieve pain, restore motion (No restrictions) Exercise within limits of pain Sometimes steroid injections may help to reduce pain and inflammation Middle  restore motion Joi8tn mobilizations, low load prolonged stretch Daily ROM, rotator cuff strengthening (reeducate on appropriate scapular movement) Late  continue to progress and return to PLOF Be cognizant of how much pain they are in Conservative therapy usually helps and it typically resolves itself over time Can have surgery for joint manipulation or have adhesions released arthroscopically Bursitis Subacromial/subdeltoid Acute  sudden onset; respond well to modalities, and education Chronic  develops gradually Primary: Degenerative changes or systemic disease Secondary: More common; typically result of other orthopedic pathologies (impingement, tear, etc.) Treatment typically cortisone injection Subjective  pain anterolateral shoulder, aggraved by overhead motions Objective  limited AROM abd/IR; pain with all resistance TTP: Below anterolateral acromial rim Subscapular Subjective  Pain over upper back, popping with shoulder shrug, difficulty sitting on hard back chair Objective  TTP superomedial angle of scapula Typically associated with other conditions Treatment aimed at reducing inflammation and treating Fractures Clavicle  Usually a FOOSH injury Present w/ guarded shoulder, difficulty lifting the arm above 60 degrees, and painful horizontal adduction May see a deformity depending on the degree of the fracture Healing time Adults  8 weeks Children  6 weeks Scapular  uncommon Humeral Head (Hill-Sachs)  compression fracture occurring in the posterolateral head, often with an anterior dislocation and accompanies a Bankart lesion GT Neck Shaft Goals Acute/inflammatory Decrease inflammation and pain Increase ROM and prevent muscle atrophy Minimize effects of immobilization Do not overstress healing tissues Subacute Restore ROM Increase strength Motor control/ proprioceptive Gradual return to PLOF/activity/sport Shoulder Examination9/9/2023 Influence on the Healing Process Age  Younger will heal faster Nutrition  Nutrients, protein, etc. will help pt. heal faster Medications  Steroids, NSAIDs, Anti-coagulants Steroids are great for repair, but also break down tissue Co-morbidities  Diabetes, CHF, smoking, etc. slow down healing process Inflammatory/acute  When prostaglandins mediate the inflammatory response Typically short period and time (5 days- 2 weeks) Pain management should be the primary goal Should not take NSAIDs at this time Proliferation/repair  5-25 days, where scar tissue begins to form Remodeling and maturation  Can go on for 21 days - 2 years Where you want to promote WB (depending on patient) Things to Consider when Developing a Clinical Diagnosis Patient age Gender Occupation Activity/Sports Onset  Traumatic vs. non- traumatic If traumatic, how did it occur? Symptom provocation Shoulder Evaluation Subjective History Chief complaint MOI (or not) What makes it better/worse Sleeping on side  reduces subacromial space (protraction reduces space) Pain  intensity, location, nature, aggravates, alleviates Lateral aspect of arm Tip of shoulder Trigger points Consider referred pain from cervical/thoracic/ribs Rule out red flags Neck vs. Shoulder Pathology Neck Pain at rest Pain w/ neck motion Pain w/ overpressure on the neck Pain aggravated by postural positions Pain past the shoulder Reflex changes Altered peripheral sensation Guarder cervical spine motion Shoulder Pain w/ use Pain when working OH Feeling of instability Local palpable tenderness Painful arc of motion Pain into the deltoid area Pain mainly on the dominant side Pain relief with local injections History and possible Dx FOOSH  proximal humerus fracture, SLAP lesion, RC tear Fall onto the shoulder  AC separation, RC tear, fracture, SLAP Trauma w/ arm abducted/ER  Anterior instability, subscapularis tear Traction injury  SLAP NO trauma, insidious  degenerative joint disease, tendinitis, frozen shoulder Weakness with no pain w/ no trauma  Muscle disease, nerve injury, chronic RC tear No trauma, severe pain  Shingles, tumor Current/ PLOF What was their functional level prior to onset Work, leisure (sports, fitness level, sedentary lifestyle), home environment etc. What is their current functional level compared to prior Functional outcome measurements  DASH, Quick DASH, PSFS Shoulder Exam Screening  cervical/thoracic/ribs; elbow Quadrant testing Neuropathy  Suprascapular nerve, spinal accessory, axillary, long thoracic Upper Quadrant Observation Observation/Static postural exam Piano Key sign Sulcus (GH joint) Shoulder height Muscle bulk/atrophy Symmetry (shoulders/scapula) Scapula  static and dynamic Upper Cross Syndrome Tight UT and LS Tight pectorals Inhibited neck flexors Inhibited Rhomboids and SA Scapulo-thoracic Functional joint Elevation/depression Upward rotation/ downward rotation Protraction/retraction Causes of Scapular Dyskinesia Bony Thoracic kyphosis Clavicular fracture nonunion Clavicular fracture malunion Joint AC instability AC arthrosis GH internal derangement Neurological Cervical radiculopathy Long thoracic nerve palsy SA nerve palsy Soft tissue Intrinsic muscle pathology (strain) Hypomobility GH IR deficit Altered muscle activation patterns Altered force couples Scapular Dyskinesia divided into 3 patterns Type I  inferior medial border is prominent (anterior tilting) in the sagittal plane Indicated muscle weakness (traps, lats, etc) or muscle tightness (pecs) Type II  Medial border is prominent - transverse plane SLAP lesion, RTC dysfunction, weak SA, rhomboids, traps, etc. Type III  Superior border elevated – shoulder shrug initiates the movement RTC tear or tendinosis, nerve palsy (SA) Scapular Winging Dynamic scapular motion test (Kibler et al) Primary  Weakness Secondary  shoulder pathology Dynamic  winging with movement Long thoracic nerve palsy  observed on abduction and FF, pushup position Spinal Accessory nerve palsy  Scap is depressed and inferior border moves laterally (winging occurs before 90 degrees abd) Radiculopathies C3,4 – traps C5 – Rhomboids C7 – serratus, rhomboids Additional Scapular Examination Lateral scapular slide test (semi- dynamic) 1.5cm diff btw sides  positive test Scapular assistance test Flip Sign P/AROM screen AROM Painful arc (60-120)  GH (170-180)  AC Apply Scratch Test  Functional Scapulohumeral rhythm PROM End feel Flexibility (pec minor/lats/pec major) Joint mobility/Joint play  GH/scapula/AC/SC Common Patterns (ROM) Overhead throwing/activity or swimmers Increased ER Capsular pattern GH: ER, abd, IR AC: pain at end range PROM: Rotation of Humerus Seven passive rotation test positions that strain/stress specific tissues. ER at 90* in neutral  subscap ER in POS  subscap ER at 45* abd in frontal plane  middle GH lig ER at 90* abd in frontal plane  Inferior GH complex IR in POS – post capsule  superior fibers IR in 30* of ext  inferior post capsule IR at 90* of flexion  posterior capsule MMT/Myotomes Supraspinatus  90 elevation, scapular plane, full can position Infraspinatus  0 elevation, 45 IR Subscapularis  Back of hand on low back and “lift off” Belly push Palpation SC and AC joint, bicipital groove, rotator cuff insertions/ and muscle belly for atrophy, scapula Trigger points Rotator Interval Borders Superior  Anterior margin of the supraspinatus muscle Inferior  Superior margin of the subscapularis muscle Apex  Intertubercular groove Base  coracoid process Sensation Dermatomes Peripheral nerves DTR’s Assessing Joint Play Hyper/Hypo mobility  limiting ROM Multidirectional Unidirectional End feel Assessment  drives treatment Key Elements for a Clinical Diagnosis Recognize salient points in the history ID of precipitating or perplexing factors Careful Examination  Palpation of pain generating structures Lab Notes Scapular tests McClure determining scap dyskinesis 2-5lb weights in hands 5 reps of bilateral flexion f/b abduction (thumbs up) Looking for winging or dysrhythmia Normal, Subtle, or Obvious Scap slide test Measure distance between bilateral scapulae at inferior angle of scap to T6/T7 SP on each side – looking for a difference >1.5cm between sides – do this in all 3 positions In each of the 3 positions: Down at side, on hips, 90 degrees in coronal plane with IR Scapular assistance test Start with active shoulder abduction active and rate the pain. Therapist from behind stabilizing with one hand over clavicle and spine of scap with a mild downward force while the other hand is at the inferior angle of the scap – have pt go through abduction while assisting the motion through the inferior angle of the scap. If pain is absent or diminished with the assisted motion then the test is positive. Extra-articular lesions TIC for AC joint Pathology Cross-body adduction test  In sitting apply maximal overpressure into horizontal adduction (arm at 90degrees) AC resisted extension  Pt sitting arm 90 degrees of shoulder flexion and elbow flexed O’Briens test (pain elicited at AC joint is +) SLAP lesion or AC lesion. TIC for Bicep’s Tendon pathology (LHB) Speed’s  90 flexion and supination, exert downward pressure for pain in bicep Yergason’s  Tests the transverse humeral ligament (holds long head in bicipital groove). Pt. asked to have forearm flexed to 90 in full pronation, stabilized against the body. Have pt. perform resisted supination while you palpate the bicipital groove. If the tendon pops out, this indicates a tear of the transverse humeral ligament. Tenderness or pain w/o a pop is indicative of biceps tendinosis or SLAP Palpation of the LHB in the bicipital groove IRRST Used for ruling in posterior internal impingement and intra articular impairment/pathology Intra-articular lesions/ Intra-articular pathology Labral lesions SLAP tears ( 10-2) TIC ( test item cluster) Bicep’s load test 1  pt. supine, shoulder in 90 degrees abd, elbow flexed to 90. Give resistance during elbow flexion. Test is positive if pt. has pain. Bicep’s load test 2  pt. supine, shoulder in 120 degrees abd, elbow flexed to 90. Give resistance during elbow flexion. Test is positive if pt. has pain. Crank test (160* shoulder abduction) – for bankart and SLAP lesions  pt. in supine, 160 degrees in scapular plane, 90 degrees elbow flexion, provide compressive force, and bring arm in and out of ER to pinch the torn labrum. Test is positive if there is clicking with or without pain or apprehension from the patient. Active Compression test of O'Brien  shoulders flexed to 90, 10 degrees adduction, have patient fully IR and resist downward pressure. Second position is palms facing ceiling, asking them to resist downward pressure. Test is positive if pain provoked during 1st position is lessened or disappears in the second position. Bankart lesions ( 3-6) TIC Apprehension Load shift (excessive anterior translation).  pt. sitting, use one hand to stabilize clavicle and spine of scapula while you grab the humeral head with the other hand. Translate the humeral head forward and backwards (testing posterior and anterior capsule). Test is positive if one side clearly translates more than the other or if you provoke patient symptoms. Sulcus sign  Test for MDI Crank  Compressive force into the joint at 160, ER back and forth Clunk  Same thing, but distraction instead Jobe Relocation Reverse Bankart lesion (6-11) TIC Jerk Test  pt. in sitting, be behind them. Stabilize scap with one hand, hold pt.’s affected arm in 90 degrees abduction and IR, apply compressive force while you move the patient into horizontal adduction. A positive test is a sudden “clank” as the humeral head slides off the glenoid. Abrupt pain may also occur. Kim Test  pt. in sitting. Abduct shoulder to 90 and support elbow at 90 degrees flexion. Apply compressive force to the glenoid with your body and place other hand distal to the deltoid. Elevate pt.’s arm diagonally upwards while applying a downward posterior force with the other hand. Test is positive if pt. experiences sudden onset of posterior shoulder pain and a click in the shoulder. SAPS /Rotator cuff pathology TIC for impingement or RC Tendinopathy Hawkins –Kennedy test  Elevate arm to 90 degrees forward flexion, have it rest on one of your arms and perform passive IR. The test is positive if pain is produced. (test will be negative in an internal impingement) Infraspinatus Muscle Test  Put into 0 degrees elevation and elbow flexion 90. Apply pressure pushing into IR (working ER’s) Painful Arc Other tests can be added to increase SP Neer  stand behind pt. pt. in sitting, stabilize the scap. Bring arm into max shoulder flexion. Test is positive if patient has pain. Yokum  pt. in sitting or standing. Ask shoulder to place hand of affected arm on contralateral shoulder. Pt. is asked to raise elbow without moving shoulder. Test is positive if pt.’s familiar pain is produced. External impingement and RTC tear Rotator cuff tears TIC for rotator cuff tears Infraspinatus test  Put into 0 degrees elevation and elbow flexion 90. Apply pressure pushing into IR (working ER’s) Drop arm  Raise arm to 90 abd, if pt. lacks eccentric control or has pain/compensation w/ deceleration, +. Painful arc ( 60-120) Teres Minor Hornblower’s sign  90 flexion, elbow 90, unable to resist being pushed into IR Active version: Bring hand to mouth, arm will drop if positive Subscapularis Lift –off  pt. puts hand behind back, instructed to lift dorsum of hand off of back, if unable, +. IRLS  pt. passively put into lift off position and told to hold this position. If dorsum of hand contacts the back, +.