Week 5 Msk Summary PDF

5.1 sternoclavicular jnt osteology scap humerus sternum clavicle ribs vertebrae ilium (thru thoracodorsal fascia attachment of lats clavicle...

5.1 sternoclavicular jnt osteology scap humerus sternum clavicle ribs vertebrae ilium (thru thoracodorsal fascia attachment of lats clavicle shaped like an italic ‘f’ acts as a strut to the UE to resist compressive forces (especially in WB position) medial portion moves the least main fxn: stability (portion at sc jnt= relatively immobile) scapula -thin, flat triangular shape provides a concave surface that can glide easily over the convex thorax (& ribs) scapular fxns increase the positions available for the hand in space by varying the original position of prox humerus (-basically helps get your hand in different positions) in WB, provides stability for UE during fxnal activities of hand analogy : dredging machine prox stability to allow fxnal distal mobility integrated, fxnal mvmnt emanating from prox to dist (to allow fxnal mobility)  shldr articulations (jnts) sternoclavicular acromioclavicular scapulothoracic (fxnal)- not true diarthrodial jnt glenohumeral -when one doesnt work it affect entire complex -all jnts work together to provide simultaneous mobility & stability sternoclavicular jnt only skeletal articulation bw UE and axial skeleton synovial stellar articulation (like a pringle chip) articular surfaces lack congruity -1/2 of large round head of clavicle protrudes above the shallow sternal socket) sternoclavicular jnt disc -completely separate jnt -attaches to cartilage of 1st rib and capsule capsule- v lax (for mobility) ligaments- strong & provide stability -interclavicular -costoclavicular -sternoclavicular (post portion strongest bc thiccc) sternoclavicular ligaments sternoclavicular jnt (pt 2) prox surface (sternum) sternal clavicular notch shares cartilage w 1st rib convex A-P concave vertically (cranial/caudal) distal surface (clavicle) medical clavicle larger surface w thick fibrocartilage concave A-P convex vertically sternoclavicular jnt arthrokinematic motions when convex vertically surface of clavicle moves -caudally: shldr elevates -cranially: shldr depresses when concave AP surface of clavicle moves: " -ant: shldr protracts -post: shldr retracts longitudinal rotation occurs along the long axis in a post direction so the inf surfaces face ant—CPP ↓ ↓  5.2 acromioclavicular jnt acromioclavicular jnt synovial gliding jnt w lax capsule & strong ligamentous support distal surface -acromion (flat or slightly convex) proximal surface -clavicle (flat or slightly concave) clavicle faces superiorly, posteriorly, & laterally acromioclavicular jnt role -allows scapula to glide & clavicle to rotate motion -clavicle elevated 35 degrees & rotates 45-50 degrees during full overhead elevation ACJ ligaments 1. acromioclavicular - limits 91% of AP translation 2. coracoclavicular -limits 77% of sup translation -conoid (medial): vertically oriented and created clavicular rotation when taut -trapezoid (lateral): more horizontally oriented and resists acromion from sliding under clavicle 3. coracoacromial : ‘roof’ -triangular shape from base at lat border of coracoid which moves up, laterally, and posterior to top of acromion process structural influences large prominent coracoid process -impingement of subscapularis bw coracoid and lesser tuberosity os acromiale -unfused ant acromial epiphysis -last growth plate to close (prob not til your 20’s) -if doesnt fully close; looks black in acromion fix hooked acromion (type 1 flat) -osteophytes, calcific deposits -morphology variants know her!!  acromion morphology know these types!! acromial morphology & its relationship to rotator cuff tears C acromion morphology frontal plane orientation 83% of type B had stage II or III impingement (more than a 10 degree downward slope) acromion morphology acromial morphology has a predictive value in determining the success of conservative measures and the need for surgery -67% satisfactory results w conservative management- medication, injection & therapy -type 1 acromion had a disproportionate degree of success type 1- 89% success (-non op, conservative outcome) type 2- 75% success type 3- 42% success  contradictions in the literature acromial shape/slope not useful for classification not source of pain cant distinguish symptomatic from asymptomatic acromial humeral distance is more prognostic --mully believes it has good prognostic value -he says type 1 acromion tends to be easier to rehab scapulothoracic jnt not a true diarthrodial anatomical jnt mvmnt that occurs bw the scapula & thorax due to motion contributions from SCJ and ACJ scapular position landmarks -vertebral border 2 1/2 lateral from spine - T2- superior angle of scapula - T3- base of spine of the scapula - T7- inf angle of scap scapular location resting position - tipped 10 degrees forward & 30 degrees ant to frontal plane -medial border of scapulae essentially parallel to vertebral column I slightly upwardly rotated - based of spine of scap closer to vertebral column than the inf angle scapulothoracic jnt motion 3 axes of rotation 1. AP : upward (lateral) - downward (medial) rotation 2. vertical : scapular winging (IR/ER) 3. frontal : scapular tipping or tilting (ant-forward- post backward) two translation elevation - depression protraction - retraction  scapular mobility ROM -up/downaward rot: 10-12 cm displacement of inf angles or 60 degrees total scap motion ROM -protraction/ scap motion retraction: 15 cm ROM of mvmnt -elevation/ (average size depression: 12 cm adult) of mvmnt scapular contribution of GH elevation AC and SC is what contributes to ~30 degrees of upward rot upward rot IR post tilt  5.3 GH jnt gh jnt ‘golf ball’ (humeral head) on a ‘tee’ (glenoid fossa) (not a ball & socket) -ball on a tee bc not nearly as much natural bony stability surface area of humeral head 3-4 times larger than fossa & faces medially, posteriorly, & superiorly ‘golf ball on a tee’ -structural morphology is inherently unstable rely on dynamic and ligamentous support to ensure stability gh jnt anatomy humeral neck-shaft angle (centrum column diaphyseal (CCD) angle) humeral head at 130-150 degree angle to shaft of humerus (135 typical) gh jnt anatomy humeral version (twist) humerus retroverted 20-30 degrees w respect to flex-ext axis of elbow humeral version relevance -thru excessive humoral retroversion relevant to adolescent throwing athletes to gain ER necessary to throw glenoid version & tilt glenoid fossa shape pear shaped and shallow a broader inferiorly than superiorly 5° posterior and superior inclination 5 degrees 5-10 degrees sup retroversion inclination to provide to provide buttress to buttress to ant inf subluxation subluxation  glenoid labrum anatomy fibrocartilage ring attached to the rim of the glenoid -helps deepen the socket primary site of insertion of ligaments- capsule inner surface covered w synovium outer surface continuous w capsule and periosteum of scapular neck glenoid labrum anatomy increases depth of fossa to 5mm AP and 9mm sup to inf from 2.5 mm w/out the labrum (literally doubles) estimated glenoid contact with humeral head = 1/3 without labrum; 2/3 with labrum chock block function labrum enhances concavity-compression provided by RC gh capsule anatomy attaches medially to the glenoid fossa beyond the labrum and circumferentially moves laterally attaching to the humeral neck up to 1/2” down the humeral shaft twice the surface area of the humeral head; lax with inferior recess very loose and redundant; will allow 2-3 cm of joint surface distraction shldr shirt sleeve analogy sleeve (capsule) size dictates -if armpit portion was tight it would be hard to lift shldr mobility or cross arms restrictions in range -tight in front; hard to horizontally ABD coracohumeral ligament CHL moves downward and laterally from the base of the coracoid to insert onto the greater tuberosity fills the space between the subscapularis (anteriorly) and supraspinatus (posteriorly) functions to counteract the force of gravity and checks end range external rotation, flexion, and extension RC interval combo of CHL & SGHL prevents inf translation -stretched in CVAs allowing inf subluxation when RC inactive limits ER when arm is dependent position -contracted w adhesive capsulitis  gh ligaments 3 distinct, thickened portions of the capsule on the anterior aspect of the joint Superior Glenohumeral Ligament Middle Glenohumeral Ligament Inferior Glenohumeral Ligament Complex ghj ligaments in dependent position 45° Abduction -relaxation of sup and middle -more tension on ant band of inf glenohumeral ligament 90° Abduction 90° Abduction with Internal Rotation -stability IGHLC hammock moves posterior to form a barrier to responsible of inf posterior dislocation glenohumeral ligaments 90° Abduction with External Rotation IGHLC hammock moves anterior to form a barrier to anterior dislocation -bankart lesion: no stoppage of humoral head from translating forward  5.4 Arthrokinematics Glenohumeral resting position - Tx position point in ROM where - intracapsular space = largest - ligamentous support lax allows for - lubrication - less friction - increased arthrokinematic mvmt for spin, glide, roll 50-70 degrees elevation in scap plane (which is 30 degrees ant to frontal plane) w/ mild ER 39 degrees of abd in scap plane OR 45% of available abd rom Glenohumeral closed pack position can also be closed in point in ROM where full rot, ext, abd - max articular contact full OH elevation - ligament tension 90 degrees abd & ER glenohumeral motions he’s calling Shoulder Norms this elevation Flexion (GH) - 120 Elevation range Flexion (GH & ST) - 150 sag plane flexion - ext T Flexion (lumbar hyperextension) - 180 scap plane elevation - scaption frontal plane abd - add Ext (GH w/ elbow flexed bc passive insuf of biceps) 60 Rot transverse plane internal - ER IR before GH protraction Abd 70 (sometimes lower) GH - 90 Horizontal Plane Abd - add GH & ST - 150 ER Lumbar lat flex - 180 90 Horizontal Abd 45 w/ elbow flexed Horizontal Add 135 GH Arthrokin Fwd elevation - sag plane motion on frontal plane axis - humeral head = inf glide / post roll & spins into IR beyond 90 degrees bc tension on Coracohumeral lig - Scap = post tilt/IR/upward rot num  GH Arthokin Motion IR - humeral head = post glide/ant roll - scap protraction ER - humeral head = ant glide/post roll - scap retraction Abd - elevation in frontal plane humeral head = inf slide/sup roll/spin into ER stretches axillary pouch of IGHL (sling supporting humeral head) inf glide need for humeral head to clear coracoacromial arch ER = greater clearance of greater tuberosity Shoulder Stab static mechanics - bony (if add in labrum) - ligamentous - jt pressure/volumes GH has little bony stab - normal translation of humeral head on glenoid = 50% if width post/ant - should NOT be >6mm translation from center of rot during shoulder motion Humeroscapular Stab concave on convex (think of contact lense on eye) Scapulohumeral Stability convex on concave (ball balanced on nose of seal) - glenoid always centered under humeral head A - intact capsule w/ initiation of unidirectional humeral translation B - early capsule or GHL failure @ humeral attachment on side w/ directed force. w/ capsular tension on CL side C - failure threshold surpassed @ both capsular attachment sites (grade 3 dislocation) Static Shoulder Stab - Jt pressures/volumes negative atmospheric pressure contributes to shoulder stab adhesion/cohesion: jt surfaces stick together - allows motion but not sep (like cover slips that stick but glide on slide) limit jt vol contributes to shoulder stab GHJ intra - articular jt pressure magnitude of stab pressure = 20-30lbs tears in capsule allow intro of air/fluid & reduce force necessary to translate humeral head by 50% muscle = important helps stab early throughout decreases NIP = decreased stab Dynamic Shoulder stability rotator cuff - active contraction centers GH art & compresses jt surfaces Force couples - scap & humeral neuromuscular control & fxn - increases dynamic ligament tension  5.5 Shoulder nerves/innervation Review brachial plexus! 4 innervation he’ll be going over Axillary nerve innervates deltoid (ABD) & teres minor (ER) at risk w/ - ant instab sx (adjacent to subscap & ant capsule) - posterior instab sx (emerging from quadrilateral space) - ant glenohumeral dislocations - proximal humerus fx axillary n screening test if pt can reach into front pocket (slight abd recruiting delt)  Long Thoracic N innervates serratus ant at risk w/ - chronic compression/traction - axillary incision approach of sx - neuritis (parsonage-turner syndrome) “backpacker palsy” Evaluate for “plus sign” differentiat dyskinesia from a palsy elevate to 90 degrees in sag plane & observe winging protract from this position - if scap protracts - dyskinesia - if scap wings/cant protract - palsy Spinal Accessory Nerve 11 th cranial n innervates trapezius at risk with - direct blow to top of shldr - sx complication - lymph node biopsies - neuritis of unknown origin Evaluate for “flip sign: test shldr er strength while monitoring med scap border - if scap lifts off thorax (IR) = spinal accessory n. lesion = middle/lower trap cant stab scap  suprascapular n innervates supraspinatus & infraspin at risk w/ - spinoglenoid ligament ossification - post paralabral cyst (only supraspinatus) - protracted scap - sup/post arthroscopic portals ppl who work out a lot can compress that n  5.6 Scapulohumeral Rhythm Shoulder Biomechanical Concepts Purpose of scap motion scapulohumeral rhythm maintains orientation of glenoid w/ humeral head to scapulothoracic force couples - prevent impingement/shear obligate translation - enhance dynamic stab muscular fxn Scapulohumeral Rhythm distributes elevation motion bw 2 joints permitting larger ROM w/ less compromise of stab ' maintains glenoid fossa in congruency w/ humeral head & decrease shear forces allows muscles that act on GH jt to maintain good length tension relationship & minimize active insufficiency (bc scap always moving origin & insertion relationship) Scapular mvmt w/ elevation w/o scap mvmt arm can ABD 90 degrees actively & 120 passively difference in ROM bc deltoid = actively insufficient or too short to develop enough tension w/ scap rot 2:1 Scapulohumeral Rhythm scapulothoracic jt contributes to about 60 degrees to elevation GH jt contributes = 120 to elevation -120 w/ flex - 90-120 w/ abd 2:1 OVERALL not any smaller arc initial phase of elevation - scap has inconsistent mvmt while seeking a pos of stab (setting phase) - GH is primary contributor to motion - w/ increasing ROM, scap contributes more to motion (60-120 degrees) approach 1:1 during his  scapulothoracic jt motion formula 30 degrees of sternoclavicula motion t 30 degrees of acromioclavicular motion - - 60 degrees of scapulothoracic first 90 of elevation tension on costoclavicular & corticoclavicular lig creating tension for rot @ AC jt Last 90 post rot of clavicle allows for motion scapular movement summary 0-30 degrees = early phase - min scap mvmt (3-4:1 ratio) during scap setting phase - axis of rot @ spine of scap near vertebral border above 30-60 degrees = later phase thru full elevation - glenoid fossa moves medially, tilts up (post) & rot up (1.25-2.34:1 ratio) - axis of rot moves toward glenoid fossa & @ AC jt by 90 degrees of elevation Scapulothoracic jt force couple 2 forces acting in opp dir to rot a part about its axis of motion Scapulothoracic Force couple 2 forces acting in opp dir to upwardly rot scap about AP axis Upper trap -> Lower Serratus Lower trap (once reach 90 degrees) -> Upper serratus  lower trap more active in abd above 90 degrees while lower serratus ant more active in fwd flexion once axis of rot reaches AC jt, lower trap & serratus ant become more effective in scap upward rot 30-90 = upper trap/serratus 90-150 = lower trap/serratus  5.7 RC Deltoid Force Couple Force Couple - Deltoids vector pull at GH joint is in direct opposition to the collective pull of RTC - Purpose of cuff - Decrease amount of unnecessary upward translation Does Humeral Head Depress - Cuff minimizes superior translation during active elevation - No, the humeral head does not - Humeral head will displace a little, even with intact cuff - Moves up dramatically more if RTC is deficient GH elevation Force Couple - Elevators/Compressors - Deltoid - Pectoralis - Supraspinatus - LH of Biceps - Depressors/Elevation Resisters - Subscapularis - Infraspinatus - Teres Minor RTC Dynamic Steering RTC Tendons - ISP: Infra - SSP: Supra - SSC: Subscap - CAL: Coricoacromial ligament - C: Coracoid > - RTC Cross Sectional Volume - Subscapularis: 53% (solely anterior) - Supraspinatus: 14% - Infraspinatus: 22% - Teres Minor: 10% RTC Elevation Force Couple - RTC is active throughout elevation ROM & fxns to minimize humeral head elevation - RTC mm action decreases at higher ranges of elevation as there is less need for depression of the humeral head - At higher ranges of elevation, gravity & adductors provide depression EMG Action Potential of RC through Elevation RTC Vectors - Deltoid - Dominant vector is superior (89% of total force) - Supraspinatus - Dominant vector is compression (63% of total force) - Teres Minor - Mean vector of IST is angled at 50 inferior to face of glenoid - 80% of total force Consequence of poor RTC - Force couple synergy disrupted - Alters center of ROT leading to increased humeral head excursion & degenerative changes - Loss of dynamic stability Prevalence - Average Age - 49: No cuff tear - 59: Unilateral cuff tear - 68: bilateral cuff tear - Older someone gets, the more common RTC are present - 50% asymptomatic tears will be symptomatic - Tear size increases - 50% symptomatic - 22% asymptomatic - Risk of RCT doubles if sibling experienced full-thickness tear - Genetic Predisposition Deltoid Muscle - 40% of the x-sectional mass - Cross sectional: 18.2 cm - Changing vector action - Line of pull at rest produces superior shear & 45% compressive force - At 90 degree line of pull, produces compression Concave-Convex Rule - Interrupted when we have asymmetrical tension of capsule - Convex side wants to translate away from tightness  5.8 Instability Labrum Various Shoulder Pathologies - Arthritis - Usually older - Instability - Usually younger - Labral - Adhesive Capsulitis - RTC Disease GH Joint Instability - Congruence of glenoid fossa & humeral head is not met TUBS (Torn Loose) - Traumatic (Acute Dislocation) - Unilateral (Ant or Post) - Bankart Lesion - Surgery (Sling) AMBRI (Born Loose) - Atraumatic or Recurrent - Multidirectional - Bilateral - Often congenital - Rehabilitation - 6-9 months of rehab before considering surgery - Inferior Capsular Shift - Reduce volume of lax capsule TUBS & AMBRI represent each end of instability spectrum GH Instability Methods of Classification - Frequency - Acute, Fixed, Recurrent - Degree - Subluxation, Dislocation - Etiology - Atraumatic, Microtraumatic, Macrotraumatic - Direction - Anterior, Posterior, Inferior, Bi/Tri-directional Bankart Lesion - Pathology - Periosteum & capsule of IGHL/anterior labrum complex detach from scapular neck & adhere to overlying subscapularis tendon - Anterior capsule avulsion of IGHL b/w 3:00-:00 positions Instability Essential Lesions - Bankart-Type - Detach from IGHL complex leaving attenuated, baggy capsule w/ stretched or traumatized subscap tendon - Bony Bankart Lesion - Bone fragment lying adjacent to incomplete rim of glenoid - Glenoid Fracture - Hill Sach’s Lesion - Compression fracture on posterolateral margin of humeral head as it impacts anterior lop of glenoid fossa - Traumatic GH dislocation Recurrence Risk Factors - Age, Sex, Activity Type Influence - Men 6x more likely than women Labral Lesions - Superior Labrum Anterior-Posterior (SLAP) - Detachment of superior aspect of glenoid margin at the insertion of the LH of the biceps - Increases strain on IGHL by 100-120% - MOI - Throwing athletes - Falls, direct blows, unexpected traction loads on biceps - Types - Type 1 - Degenerative/shredded - Type 2 - Most common, superior separation occurs - Type 3 - Also damage to bicep tendon, tissue flipped into joint, bucket handle tear - Type 4 - Both labrum & biceps completely separated from glenoid neck  5.9 RTC Stiff Shoulder RTC Pathology - Common occurrence - Natural degenerative tendon change as we age Shoulder Bursae - 8 different bursa in the shoulder, subacromial bursa most clinically relevant - Separates supraspinatus tendon from acromial arch, deltoid, & humeral head - Source of inflammation in impingement syndrome - Can be called Bursitis, Pain Syndrome, Impingement Syndrome - Space to pass through - 9-10 mm clearance w/ arm at side - 6-7 mm clearance w/ arm in FLEX/IR - Possible causes - Pathological changes underneath the coracoacromial arch - Compressions of suprahumeral structures against anteroinferior aspect of acromion & coracoacromial ligament - RTC related disorders are combo of intrinsic & extrinsic factors - Intrinsic tension overload & intratendinous degeneration - Results from limited vascularity & external compression Progression over time Adhesive Capsulitis (Frozen Shoulder) - Common pathology that is difficult to define, difficult to treat, difficult to explain - Prevalence - 2-5% of normal population - Middle adult aged, usually in women - Progressive condition of uncertain etiology in which there are spontaneous inset of pain & gradual loss of active/passive shoulder motion - Pathology - Irritation of GH synovium w/ chronic capsular inflammation - Capsular fibrosis & perivascular infiltration of adhesions into lax folds of ANT & INF capsule - Obliteration of joint cavity - (20-30 mL decreased to 5-10 mL) - Contracted RTC interval & CHL - Thickened contracted capsule holding HH tightly on glenoid fossa - RTC contracture - “Shrink Wrap” GH Osteoarthritis - Radiologic Mnemonic - Loss of joint space (narrowing) - Osteophytes GOAT BEARD PRESENTATION - Subchondral Sclerosis - Subchondral Cysts - Severity Scales - Kellgren-Lawrence - Grade 1 - Doubtful narrowing of joint space & possible osteophytic lipping - Grade 2 - Definite osteophytes & narrowing of joint space - Grade 3 - Moderate multiple osteophytes, definite narrowing, some sclerosis, possible deformity of bone contour - Grade 4 - Large osteophytes, marked narrowing, severe sclerosis, definite deformity of bone contour GH Osteoarthritis - Severity Scales - Weinstein Scale - Stage 1 - Normal radiograph, arthroscopic evidence of articular cartilage changes - Stage 2 - Minimal joint space narrowing w/ concentricity of humeral head & glenoid - Stage 3 - Moderate joint space narrowing w/ early inferior osteophyte formation - Stage 4 - Severe joint space narrowing w/ osteophyte formation & loss of concentricity b/w HH & glenoid - Articular Cartilage Scale - Grade 0 - normal - Grade 1 - Softening or swelling of cartilage - Grade 2 - Partial thickness fragmentation or fissuring effect that don’t reach subchondral bone - Grade 3 - Focal ulceration to level of subchondral bone in area w/ diameter > than 1.5 cm - Grade 4 - Exposed subchondral bone - Clinical relevance - Amount of joint space does not correlate to level of pain, amount of mobility, or level of fxn Key Points - Shoulder fxn relies on contributions from multiple joints - Acromial morphology is not diagnostic but has prognostic quality - Tri-planar contributions to scapular motion are essential to full, pain-free fxn - GH joint is architecturally unstable & relies on labrum, capsule, & RTC for stability - GH stability enhanced by scapular positioning, intact capsule w/ negative intra-articular pressure, cohesion - Peripheral nerve integrity tempers/control normal shoulder fxn - Scapulothoracic & GH provide normal overhead elevation - Shoulder instability defined by frequency, etiology, degree, direction - Adult to geriatric pathology involves RTC, capsular mobility, & articular carriage health - Shoulder pathology presentation is overlapping & multifactorial  5.10 shoulder exam introduction shldr pathology is.. common... almost everyone will encounter disabling... impacts/limits many common ADLs recalcitrant... rarely fully recover - bc cant or not proper tx recurrent... prone to returning subjective hx: points of emphasis age/sex shldr pathology is age specific hand dominance 13-30: instability chief complaint 31-45: subacromial pain; multiple dx’s pt goals-concerns-expectations 46+: adhesive capsulitis, RC tear, DJD (OA) MOI and IDF changes (chronic or insidious) previous tx -medical/therapeutic/self date of injury/surgery meds/injury estimated probability of age/sex on recurrent instability for 2 years following index injury Inverse linear relationship As age goes up recurrence goes down -males> females -age may also be value in knowing… patient centered examination BMI what does the pt think is wrong? -their perspective co-morbidities what does the pt need/want? -thyroid what probs are important to the pt? -diabetes what is the pt’s expectation? -OA -visit may be routine to you but not for them- -hypercholesterolemia fam hx work/recreational requirements pyschosocial hx and circumstances symptomatic complaint current status work requirements & ability (demand) symptomatic complaint- pain location, nature, severity, duration, aggravated or relieved by -neuro or vascular complaints -venous complaints- swelling and stiffness -arterial complaints- pallor, coolness, cramping -Severity-Irritability-Nature-Stage (SINS) -severity -how significantly this impairment affects the pt -irritability -reactivity or stability of condition -what does the pt have to do to set off condition? -once set off- how long and severe are sx’s? -what does the pt have to do to calm sx’s?  -nature -numbness/tingling, weakness, popping, locking, giving way, clicking, grinding, skin changes -stage -has the condition stabilized (better), become stagnant (same), or deteriorated (worse)? first tx decision: are you going to treat their pain or tissue irritability guides intensity of physical stress impairment type-irritability level also guides intensity of intervention tactics *he mentioned an article of his but not important info (more for your reference if you want it* be comfortable identifying the bony/soft tissue structures on this A/P radiograph good reminder on limitations of imaging MRI finding were most equally frequent on uninvolved side in pts w unilat shldr pain while MRIs can accurately identify tissue pathology, they cant discriminate whether the pathoanatomy is associated w specific clinical presentation or complaint more to confirm  shldr pain mapping -remember pain on palpation is SN but not very SP injection of hypertonic saline into health AC jnt and SA space subjective hx past med hx- systems review -previous related injuries -fam hx diagnostic studies 2 -radiographs pain above clavicular level -arthrography indicates ACJ involvement -MRI/ CT scan (rule in with x-ray) or -EMG/NCV cervicothoracic contribution to problem shldr specific red flags potentially affecting diagnosis severe &/or persistent pain un relieved w rest or aggravated by exam, activity or exertion soft tissue mass on palpation absence of sleep disturbance -90% of pts w shldr pathology have sleep quality decline systemic illness/constitutional sx’s -fever, sweats, excessive fatigue, nausea/vomiting, unintentional wt loss pleuritic sx’s -persistent cough, SOB, blood in sputum -more comfortable lying on involved side differential dx: unlikely (but possible) causes to rule out spleen, heart, gall bladder, or lung involvement kehr’s sign -referred pain to L shldr following blunt trauma to spleen; may have concurrent hypotension myocardial or pericardial disease -heart attack often causes L shldr pain; usually pt has other risk factors like HTN, diabetes , smoking, fam hx ect gallstones -pain referred to R scapula; usually associated with indigestion and pts over 40 neoplasms-lung cancer -pancoast tumor at apex of lung -research pt w -low HDL -cholesterol -high triglycerides -over wt -pre or in fact diabetic -HTN = high risk for shldr pain (RC tendinopathies and tears)  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, & coping skill psychosocial status- anxiety, depression ect factors to baseline monitor pain level self report fxnal and psychosocial status pt satisfaction (monitor only) -overall impression and their progress toward established goals secondary considerations -mobility and strength impairments outcome measurement tool - 2-point change on the scale is considered a meaningful clinical change Patient’s rating of their overall condition since the previous evaluation -=worse +=better single assessment numerical evaluation how would you rate your shldr today as a percentage of normal? 0-100% scale w 100 being normal SANE -do frequent -likert scale  outcome assessment tool 1. DASH (Disabilities of the Arm, Shoulder, Hand)- most common 2. CMS (Constant-Murley Score) 3. ASES (American Shoulder-Elbow Surgeon’s Assessment Form) 4. UCLA (UCLA Rating Scale) 5. SPADI (Shoulder Pain And Instability Index) 6. SST (Simple Shoulder Test) 7. WOSI (Western Ontario Shoulder Instability Index) 8. PENN (Penn Shoulder Scale) outcome assessment tools quickdash- abbreviated version of DASH 11 questions converted to a 100 point scale regarding pain and fxn w options work and sports modules correlates strongly w full DASH (r=0.98) clinimetric qualities -test-retest reliability ICC=0.90-0.96 and SEM=4.6 points -MCID=10/14 points for DASH/Q-DASH** -MDC/MCID = 11/19 points*** pittsburgh sleep quality index 0= excellent sleep 21= worse sleep of your life Global – sum of 7 parameters Quality – self described from very bad to very good Latency – how long it takes to fall asleep Duration – actual number of hours of sleep Habitual Efficiency – % of time up at night Medication – frequency of need for medication to assist sleep Disturbances – reasons and frequency of awakenings Daytime Dysfunction – ability to stay awake and impact on daytime attitude pain self-efficacy questionnaire -can use for any body part -10 point likert scale Recovery expectation and self-efficacy score have powerful influence on outcomes – particularly if high initial levels of pain and disability shldr examination overview 4 key elements 1. inspection-observation - posture, spinal-scapular-humeral positions -symmetry (life if their an over head athlete) -scapulohumeral rhythm -cervical clearning 2. ROM -quality and quantity -substitution patterns -fxnal reach test 3. palpation 4.MMT -scapular and RC  shldr examination overview observation/inspection: posture body type: endo-ecto- mesomorphic scapular/shldr alignment (normal and CL side) soft tissue swelling, effusion, atrophy ect symmetrical appearance -“popeye bicep”, congenitally high or undescended scapula anatomical deformities -step deformity, sprengel’s deform, winging scapular ect “you can see a lot by looking” scapular dyskinesis examination Scapula - malposition Infera - inferomedial prominence -very forward Coracoid - tenderness DysKinesis - abnormal movement S3 – Stupid Scapula Syndrome were shoulder doesnt know wtf do to at the right time type 1 inf scapular border dysfxn inf medial border (inf angle) is prominent dorsally inf angle tilts posteriorly; acromion ventrally sag plane rot around a scapular plane axis resulting in a forward (ant) tilt of the scap coracoid tender due to tight pec minor and biceps potential tx considerations *he has most common w RC impingement’s videos to stretch pec minor see what it looks like* strengthen/facilitate serratus type 2 medial scapular border dysfxn medial border is prominent as entire vertebral border wings off the thoracic wall transverse plane IR of scap *has video for weak serratus and tight post glenohumeral structures this one too* potential tx considerations most common w instability stretch/mobilize post GH capsule strengthen/facilitate serratus (important scapula ER) type 3 superior scapular border dysfxn sup border of scap is prominent excessive sup translation (elevation) of sup border of scap on thorax w elevation maneuvers potential tx considerations most common w CT involvement stretch levator scapulae strengthen/facilitate lower traps  reliability of qualitative evaluation of scapular dysfxn low intra-intertester reliability w k ranging from=0.2-0.5 (poor moderate agreement) better agreement if just deciding yes or no in each cardinal plane (tilted or not; elevated or not, rotated or not) more obvious abnormalities in elevated positions IMO (mully)- still has value in that it focuses attention of proximal, dynamic control CSM poster-2016 (mully and dickson did this one) asymptomatic classification reliability best way to say -not perfect but really good Subject to confirmation bias as unblinded examiners more likely to identify dyskinetic movement patterns ^ research Prevalence of dyskinesis not significantly lower in non- symptomatic subjects Prognostic value of isolated risk of injury is negligible risk ratio= 1.07 spinal posture influence on shldr elevation increased cervical flex -decreased UR and post tilt increased thoracic flex -increased sup position and decreased post tilt -very kyphotic= lack of slouched posture (vs upright) rotation of elbow -decreased UR and post tilt rule out cervical spine involvement cervical radiculopathy CPR Arom in all planes w over pressure Spurling’s test (SN-30, SP-93) more of case control design w high risk for selection bias w suspect reference standard SN= 96; SP=96 NPV=99; PPV=95 + LR= 24, - LR= 0.04 dont forget to clear the thoracic spine flex/ext side bending rot  5.13 Shoulder Mobility & Strength Range of Motion Testing AROM puts stress on contractile/non contractile tissue PROM puts stress on only NON contractile tissue Be aware of norms & testing reliability/validity Consistent techn w/ knees eye for substitution patterns Shoulder ROM Flexion - 120 GH, 30 scap tilt, 30 spinal ext abd IR - 70 before shldr protraction ER @ 0/90 - 75/90 *can compare to uninvolved side to see their norm * Horizontal ABD - 45 w/ elbow flexed Horizontal ADD - 135 ROM assessment considerations elevation - plane of assessment - allowance for scap tilt/lumbar hyperext - slight elbow flexion so LH of triceps doesn’t restrict motion IR/ER (try to keep elbow at 90) - allowance for elbow ext or scap tilt-rot - plane of assessment & degree of elevation - scapular (not humeral head or visual) stabilization meaningful change may be up to 15 degrees (SER 5-10 degrees depending on plane) Effect of age. sex, & handedness on ROM female ROM > Male ROM decreases w/ age for all motions EXCEPT IR w/ increasing age dominant arm ER rom > non dominant in all ranges of ABD non dominant arm IR/Ext Rom > Dominant arm no difference in ROM for flex/abd Rotational Normals - Total arc whats normal? - activity specific - age, sex specific - total range theory adaptations - osseous - humeral retroversion - arm will look ER when going into horizontal ABD, neutral if they don’t have it - glenoid(scapular) retroversion - capsular - muscular End feels for the asymptomatic or normal shoulder firm capsular or muscular tension for rotations, flexion, extension, add & horizontal add - IR @ 90 > ER at 0 > flexion > ER @ 90 soft tissue approximation for horizontal add firm capsular/hard bony end feel for abduction - premature contact of the tuberosity w/ acromion Pain resistance sequence selections: sequence of paint o the motion barrier pain before, at, or after initial tissue resistance met - 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 - end range elevation usually means AC joint painless: tolerate OP @ EROM further stressing the jt Fxnal Reach Test / Apley Scratch Test Behind Back Reach - reach behind back & attempt to touch highest vertebral sp - quick test of ext/add/IR Normal = T5-6 (where thumb reaches) need this to reach in front/behind us not just one plane Cross Body Reach reach across the chest & over shldr attempting to touch opp scap (or goni 45 degree angular reach) or inclinometer assessment made by measuring linear dist b/w elbow crease & ant face of acromion quick test of horizontal add/IR, testing tight posterior capsule normal = 15-20cm  Behind Neck Reach reach behind head (in scap plane) & attempt to touch as far down on vertebral column as possible quick test: elevation/ER normal = T1-2 MMT important to know reliability, construct validity, relevance of each!!! Study from 2003 using HHD supraspinatus to deltoid EMG ration (3.4) max @ 30/30/ER position traditional empty pos had lowest EMG ratio (0.8) conclude: maybe isolate in 30 degrees Another Mully Study Assessing ER strength - position matters greatest torque production in resting position of 45 degrees elevation in scap plane ER/IR Ratio = approx 85-90% in normals able to differentiate symptomatic from asymptomatic subjects by middle trap to ER strength ratio in both sitting positions  Another Mully study… MMT for shoulder pathology had to have at least 15-25% deficit in torque generating ability (dynamometer) in order to classify muscle/mvnt as “weak” or “asymmetrical” DONT GUESS! USE DYNAMOMETER! Palpation position, tenderness, nodules, swellings, crepitus, vascular pulses, or temp change - positional relationships - HH or scap positions - coracoid tenderness - SICK scap & or adhesive capsule this - RC: more SN than SP (SS/LHB) - ACJ (everyone has OA over 40)  5.16 Special Tests, Instability what is a special test maneuver used to shift the probability of condition being present or absent NOT definitive test Best special test = taking a good hx Possible Starting Rationale for Special Tets manual stability special tests (pt has strong ER vs IR) laxity detection - sulcus test - MDL aka multidirectional laxity (inferior) - load & shift - A/P translational proactive maneuvers - apprehension sign - relocation test - anterior release/surprise - posterior push/pull Sulcus Sign see if we can make excessive space b/w humeral head below acromion >2 cm dimple beneath the acromion w/ inf glide = innate capsular lax & multidirectional laxity/ instab influenced by posture & tone mod agreement & kappa coefficient values traction creates dimple What if you’re naturally lax - brighton criteria most accurate if concurrent findings of apprehension (either dir), excessive abd ROM, & + beighton scores + beighton score = MDL like someone w/ elders-danlos syndrome Laxity Tests - load & shift “center” & shift (aka humeral head in center then shift a/p) high specificity & low sensitivity for grades 2 & 3 poor reproducibility for grades 1 laxity & reproducibility significantly improved when pt is anesthetized Instability Grading normal total AP translation = 15-50% ant & 25-50% post of humeral head width - grade 0 = lil to no mvmt - grade 1 = shifts to edge of glenoid - grade 2 = shifts over edge but spontaneously reduces - grade 3 = dislocates Laxity Testing Reliability & Diagnostic Accuracy Sulcus SP = 93 SN = 17 +LR =2.4 -LR = 0.89 mod kappa coefficients Load Shift high SP low SN Provacation Tests - trying to see if laxity is cause of symptoms Apprehension Test - put shldr in close pack or compromises ligaments key finding = apprehension or reproduction of instab symptom high SP, mod SN when using apprehension as a gauge poor accuracy if using pain as gauge of outcome Apprehension Test Study Example concluded that younger the pt higher chance of pathology 20s-30s Take Home of Shoulder Stability Testing: Diagnostic Accuracy Summary Stability testing = higher SP than SN + = instability is most likely part of the problem Testing for Posterior Instability Push Pull Test L Hand = pushing humeral head in post dir R hand = applying tx pt presents with MDL can voluntarily dislocate shldr excessive pain/ttranslation w/ stress on post capsule generally SP not SN underpowered, singular studies w. selection bias issues  5.15 Special Tests Subacromial Pain Subacromial Impingement Testing flexion - IR - Horizontal ADD - induce anterosuperior obligate translation hawkins - kennedy & Neer - Walsh - SN - hawkins: horizontal ABD w/ OP IR - Neer walsh: flexion w/ IR Clancy - min diagnostic value - emphasis on horizontal ADD Yocum & Jobe Test - SP from Mully experience - elbow twd forehead w/ flexion, horizontal abd, IT Presence of Painful Arc - SP Neer Walsh Maneuver prevent thoracoscapular mvmt by providing depressive force on acromion maximally elevate the IR arm known for high SN than SP w/ - LR - suggests small shift in probability Hawkins - Kennedy Maneuver shoulder in 90 flexion w/ elbow flexed stab scap forcibly IR by lowering forearm higher SN than SP w/ - LR ratio - suggest small shift in probability Clancy Maneuver provide OP to end range, horizontal ADD, while keeping arm elevated to 90 & IR suspect, very small shifts in post test probability to rule in/out impingement questionable value - probably more likely AC involvement steps for provacation tests Painful Arc just lifting arm in any dir SP not great Supraspinatus Empty Can (Jobe) long lever arm w. IR like pouring one out apply resist to see if theres a tear, weak, or painful mod SP and + LR  Conclusion no single test can shift the probability significantly of SAPS (subacromial tissue injury) being present or not impingement tests tend to be somewhat SN but not SP common SAPS impairments seem to have more (unproven) specificity value Park Study: suggests that a cluster of tests can help LR + and - Best (most accurate) Combination Subacromial Impingement Syndrome + hawkins-kennedy (park) or + neer (michener) presence of a painful arc weakness in ER + LR > 10, - LR 10 degrees indicates infra tear - Drop Sign - Highly SP, moderate SN - At 90 degrees indicates Supra & infra tear - Subscapularis Tests - Belly Press Test - Can maintain elbow anterior to frontal plane - Good alternative if too painful or stiff to place hand behind back - 79% SP, 67% SN - Lift Off/IR Lag Sign - Lift Off - Can they lift their hand off their back - IR Lag Sign - Can not keep hand off back - Bear Hug - Positive test results when patient can’t hold hand against shoulder as examiner applies ER force - 60% SN, 92% SP - Supine Napoleon - MULLYS FAV - SP/SN: 96/84 - Basically belly press but utilizing gravity - Position - Patient lays supine, elbow passively lifted off - Patient has to maintain position, positive test if they can’t RTC Cluster Testing - Individual tests for RTC tend to have poor overall accuracy - ROM Limitations - Muscular Weakness - Patient Demographics - Special Tests - Litaker Clinical Cluster - 5 Point Scale - 2 points - age > 65 - 2 points - ER MMT Weakness - 1 point - night pain - Combined score > 4 (+LR) - Combined Score < 2 (-LR) Predictive Model for Diagnosing RTC - Presence of these variables increases probability of RC tear - Male - Weak ER - Positive Lift Off Test - Positive Jobe Test  5.17 Special Tests: Labral Pathology SLAP - Superior Labral Anterior to Posterior lesions - Types - Type 1 - Labral Shredding - Type 2 - Labral Avulsion - Type 3 - Labral Bucket Handle Tear - Type 4 - Bicipital Tendon Involvement Subjective History - Mechanical symptoms w/ weakness - “Clicking” in my joint w/ weight training - Losing velocity & unable to get arm to “loosen” up Common SLAP History - Pain tends to be present w/ activity & goes away w/ rest - Unless RC also involved - MRI evidence of SLAP lesions are extremely common in asymptomatic adults - Up to 70% - Males Selection of Tests Shortcomings of Labral Testing - Diagnostic accuracy of SLAP tests is inconsistent secondary to - Great propensity for concurrent co-mobidities - Wide variety of superior labral pathology - Wide variety of MOI - Shear, tension, degeneration - Inconsistent reference standards - Best to use cluster testing Superior Glenoid Labral Pathology Tests - Active Compression Test (O’Brien Test) - 90 elevation w/ 15 horizontal ADD - Resistance to elevation applied in both IR/ER positions - Superficial Symptoms - AC - Deep Symptoms - SLAP - Positive Test - Test w/ alleviation of “deep” symptoms in supinated/ER position - No ones able to reproduce high SP/SN reported by O’Brien initially - SN = 72, SP = 52 - Resisted Supination ER Test (Myers Test) - Patient passively positioned at 90 ABD, 65-70 elbow FLEX, neural forearm - Examiner simultaneously resists forearm SUP while passively ER shoulder - Positive Test - Report of deep ANT shoulder pain or mechanical reproduction of symptoms present when throwing - Moderate shifts in + & - LR if reproduction of deep shoulder pain - Test only proven accurate in dominant arm of overhead athletes - Passive Compression Test -Stabilized affected shoulder by holding ACJ in 1 hand, patients elbow in other - Shoulder ABD to 30 & ER - Simultaneous compression force in SUP direction along the long axis of humerus while EXT the shoulder - Positive Test - Present if reproduction of pain or mechanical clicking Tests - Modified Dynamic Labral Shear Test - Uncomfortable for the patient, sometimes painful - ANT translation applied while elevating in frontal plane overhead - Positive Test - Posterior pain or click b/w 90-120 degrees - Isolated: SN(78), SP(52), OR (1.4x) - Combo w/ other tests did not improve diagnostic accuracy What about combination of tests? - Parallel - If any 1/2 or more tests is positive - Exam is considered positive - Decrease false negatives, increases false positives - Serial - 2 or more tests applied sequentially & all must be positive to render positive findings - Decreases false positives - When applied to SLAP testing - May render improved SP in series - Study says you need 2 tests - May render improved SN in parallel - Study says you need 4 tests  5.18 Special Tests for ACJ & Neuro Screen AC Separation - Can be hyper mobile - Separation b/w clavicle & acromium - Normal Values - Normal Joint Space: 0.3-0.8 cm - Normal Coracoclavicular Distance: 1-1.3 cm - Can recognize a step off deformity visually ACJ Grading - Type 4-6 are surgical stabilization solutions - Type 3 controversial, depends on what the patient needs to do with the arm - Type 1-2, slight AC sprain/full Confirmation of ACJ Arthrosis - Symptom reproduction - Direct Palpation - Help rule OUT - Cross Body ADD - Pain at end range ELEV - Superficial pain w/ O’briens test - Help rule IN - + Paxinos Test - Help rule OUT - No clear method to diagnose degenerative ACJ pain Neurological Screening - Significant weakness in muscle during isolated MMT - Subjective complaint of parathesia or numbness - History of injury that would produce neurological result - Humeral Dislocation - Check radial nerve - Brachial Plexus involvement, secondary to traction injury or thoracic outlet compromise Neuro Exam - C5-C6-C7 Reflexes - Dermatomes - Nerve Root Motor Fxn - Dermatome Reminder - C4 - Shawl Area - C5 - Deltoid Area - C6 - Thenar Eminence - C7 - Dorsum of 2-3 digit - C8 - Ulnar border of 5th digit - T1 - Medial Forearm - Myotomes Reminder - C4 - Shoulder Shrug - C5 - Shoulder ABD - C6 - Elbow FLEX/Wrist EXT - C7 - Elbow EXT/Wrist FLEX - C8 - Thumb EXT - T1 - Finger ABD - Reflexes - C5 - Biceps - C6 - Brachioradialis - C7 - Triceps Upper Limb Tension Tests - BASE - Neck FLEX - Shoulder Depression - Shoulder ABD - Sensitizers - Shoulder Rotation - Elbow FLEX/EXT - Forearm Pro/Sup - Wrist & Finger FLEX/EXT - Wrist Deviation Nerve Injury Provocation Take Home Key Points - If nothing else, know age, sex, MOI, symptom location, & level of tissue irritability from history - Head up for yellow/red flags. Monitor more than impairments, remember psychosocial influences - Screen proximal involvement, adverse neural tension, & understand scapular asymmetry may be reasonable compensation - Appreciate limitation of range & test, don’t guess on muscle strength is > 3/5 - Laxity & apprehension tests tend to confirm instability (Rule in) - Impingement tests to screen subacromial tissue involvement (Rule out) - Use physical exam maneuvers to help clarify source of subacromial pain syndrome contributors - Contractile tendon tests for biceps/RTC status tend to be specific or benefit cluster findings - All labral provocation tests are limited in their diagnostic accuracy. - History/MOI likely more insightful - AC joint dysfunction tends to be local in symptomatic presentation