OCCTH 583 Shoulder/Elbow PDF

OCCTH 583 SHOULDER Jennifer Krysa, MSc, OT Reg (AB), OTR The Shoulder Complex Anatomy Osteology Joints Musculature Innervation Assessment Pathology Shoulder Anatomy - Osteology 3 Bones: Scapula Humerus Clavicle Scapula Positions gl...

OCCTH 583 SHOULDER Jennifer Krysa, MSc, OT Reg (AB), OTR The Shoulder Complex Anatomy Osteology Joints Musculature Innervation Assessment Pathology Shoulder Anatomy - Osteology 3 Bones: Scapula Humerus Clavicle Scapula Positions glenoid fossa for humeral motion Clavicle Positions humerus laterally away from upper body Humerus Shoulder Complex – 4 Joints Scapulothoracic joint Sternoclavicular joint Acromioclavicular joint Glenohumeral joint  Scapulothoracic Joint Articulates with ribcage Spans ribs 2-7 Has 6 motions: Elevation & depression (glide) Protraction & retraction (glide) Upward & downward rotation Sternoclavicular Joint The only bony point of attachment for the upper limb Substantial articular disc inside jt. which adds stability Try It – SC Joint Movements While Elevate & depress your shoulder palpating Protract & retract your scapulae your SC ER & IR your humerus joint:  Acromioclavicular Joint Augments ROM of the humerus Fibrous capsule surrounds joints Articular disc inside the joint AC jt. with SC jt. enable the humerus to fully abduct to 1800  Glenohumeral Joint Depends on muscles rather than bones or ligaments for support Labrum deepens the glenoid fossa Sits in higher point of glenoid and lowers when R-cuff contracts allowing full abduction Shoulder Complex – Muscles Shoulder Complex - Actions Shoulder Complex – Nerve Supply  Rotator Cuff Supraspinatus  abduction Infraspinatus  ER Teres minor  ER Subscapularis  IR Scapulohumeral Rhythm 2:1 ratio of mvmt during abduction 600 scapula & 1200 humerus Humerus laterally rotates to clear acromion The clavicle is in action (elevation & rotation) throughout and without its action abduction would be limited to 1200.  Reverse The scapula moves more Scapulohumeral than the humerus Rhythm Shoulder hike is initial movement Assessment Observation Active Movements Passive Movements Strength Testing Functional Assessment Special Tests Observations Natural alignment of body parts e.g. head to shoulder, and posture e.g. shoulder heights Spontaneous movements & function e.g. reaching for a door, removing a jacket Lack of spontaneous mvmt, guarding or bracing Skin condition in affected body part Deformity e.g. sulcus sign, winging Functional Assessment The are a variety of scales As experts in activity and occupational analysis OTs typical assess function on what the client needs to do and wants to do e.g. Self-care Productivity Leisure Shoulder Pathology - Examples Separation & Bone: fracture, Capsule: tear, Ligament/capsule: dislocation, degeneration thickening tear subluxation Muscle: tear, Tendon: tear, infection, tone Bursa: Adhesive capsulitis inflammation, (stroke), biceps inflammation impingement rupture Nerve damage e.g. brachial plexus Vascular injury Fracture Clavicle: often figure of 8 bracing Humerus Impacted neck: stable Shaft: thick periosteum so may heal on its own Gravity can provide the traction need to reduce the fracture May require surgery ORIF Adults: MOI is falls Osteoarthritis Wear & tear arthritis: articular cartilage wears out Eventually affects the bony surfaces causes bony degeneration Changes the joint shape and thus the forces acting through the joint which leads to bone remodelling e.g. osteophyte formation Pain and stiffness increase while joint mobility decreases High risk for decrease in overall activity Capsule Pathology/Ligament Tear Often traumatic event Common injury Tears tend not to heal back to normal (over elastic) Grade 1: Mild stretching without tearing of the ligaments. There may be some minimal instability of the joint at this point. Grade II: some fibers of the capsule tear, causing the head of the humerus to slip and almost dislocate (subluxation), creating a feeling of instability. Grade III: complete disruption of the joint capsule and displacement of the humeral head out beyond the joint (shoulder dislocation). The dislocation can be in any direction or result in multidirectional instability, which means the humeral head moves too far in many directions. The most common direction for shoulder dislocation is anterior, followed by posterior, and infrequently is multidirectional. Capsule/Ligament Tear Symptoms: point tenderness Aggravating factors: lifting objects, combing your hair, reaching behind Surgery may be indicated Treatment: RICE Movement in pain free ranges Taping Loading bearing and mobility exercises (when pain resolved)  Shoulder Separation Disruption of AC joint Pain Step deformity or protrusion Dislocation & Subluxation Displacement of the humeral head 95% are anterior Treatment usually includes immobilization Often results in damage to the labrum creating more instability Common in > 30 y.o E.g. inferior subluxation with hemiplegia or anterior dislocation with forceful ER Special Tests: Anterior Instability Apprehension (crank) Test: Position Pt in supine and abduct arm to 90 d then ER slowly & cautiously +ve: fear or verbalization Relocation (Fowler) Test: As above then apply a posterior force on arm +ve: apprehension and/or pain disappear Load Shift Test: Pt sitting with hand resting in lap. Therapist loads the humeral head into the glenoid then shifts in multi directions to determine amount of translation +ve: > 25% of humeral head shifts Special Tests: Inferior Instability Sulcus sign: Position in standing with arm relaxed at side. Therapist grasps forearm distal to elbow & pulls distally. +ve: sulcus sign Adhesive Capsulitis Frozen shoulder Thickening of the capsule Often after prolonged immobilization of the shoulder More common in women; 40-60 y.o. Diabetes is a risk factor Self-limiting Hydrodilatation  Adhesive Capsulitis Stages 1. Painful: moderate limitation of ROM & aching pain. Up to 3 mo 2. Freezing: severe limitation of ROM & severe pain. 3-9 mo 3. Frozen: stiffness and pain may be present. 9-14 mo 4. Thawing: gradual improvement in ROM & minimal pain. 15-24 mo Rotator Cuff Injury Acute or Chronic Age: > 50 % of people > 60 years In younger population: repetitive overhead movements In older population: very common, progression of symptoms Body mechanics: repetitive overhead mvmts Injury usually due to forceful loading of shoulder while elevated Supraspinatus is most commonly injured Rotator Cuff Painful Arc Pain, weakness, decreased range of motion, clicking, catching stiffness, crepitus Impingement Soft tissue: (rotator cuff, bursa, tendon) pinched or impinged under the acromion during overhead activities Gradual pain front and side of shoulder and into arm, decreased ROM, weakness, night pain Contributing Factors Structural abnormalities Inflammation Shoulder instability Special Tests: Impingment Neer impingement test (of supraspinatus or biceps tendon) Passively forward flex arm in medial rotation +ve: reprocess symptoms Special Tests: Muscle or Tendon Pathology Supraspinatus Palpation handcuff position Empty Can test (supraspinatus) 90 d scaption in full IR. Resist therapist’s downward pressure +ve: pain and/or weakness Drop Test (infraspinatus & supraspinatus integrity) Place Pt. in 20 d scaption with flexed elbow & full ER. Support elbow & ask Pt to hold position +ve: arm drops into IR Bursa Pathologies Bursas are found in the gliding surfaces between two friction areas; aiding in shock absorption Inflammation Rupture Deterioration MOI: usually overuse or impingement Winging Scapula Weakness of rhomboids Nerve damage Long thoracic nerve (serratus anterior) Spinal accessory nerve (trapezius) Special test: Standing facing a wall. Have Pt go in push up position with hands on wall and elbow fully extended. Push on wall. +ve: scapula protrudes OCCTH 583 ELBOW Jennifer Krysa, MSc, OT Reg (AB), OTR Elbow Anatomy Osteology Joints Musculature Innervation Pathology Assessment 6 Humerus Trochlea:  Articular surface for ulna Capitellum:  Articular surface between ulna and radius Coronoid fossa:  Superior to trochlea Radial fossa:  Superior to capitellum Olecranon fossa:  Posterior surface proximal to trochlea 6.3 Humerus P. 187–188 6 Ulna Trochlear notch:  Ulnar socket that articulates with the trochlea Olecranon process:  Posterior projection of ulna at the upper portion Coronoid process:  Lower portion of trochlear notch  Projects anteriorly 6.6 Ulna and radius P. 189–190 6 Joints The elbow and forearm work together like a rotating hinge. Joints: Humeroulnar joint Humeroradial joint Proximal radioulnar joint P. 191 6 Humeroulnar Joint Movements:  Flexion  Extension 6.10 Joints of the elbow and forearm P. 192 6 Humeroradial Joint  Flexes and extends around the capitellum  Less bony surface contact and congruity  Radial head pivots relative to the capitellum with forearm rotation 6.14 Humeroradial joint. The radial head rotates with forearm supination and pronation. P. 193 6 Proximal Radioulnar Joint Annular ligament:  Holds radial head in radial notch of ulna  Wraps around radial head 6.15 Ligaments of the elbow P. 194 6 Carrying Angle Typical Angle is 5-15 degrees Cubitus varus:  Angulation of the elbow positioning the forearm closer to the body (medial) Cubitus valgus:  Angulation of the elbow positioning the forearm farther away from the body (lateral) 6.13 Cubitus varus (right elbow) and cubitus valgus (left elbow) P. 192–193 Elbow - Muscles Flexors Extensors Biceps brachii Triceps brachii Brachialis Anconeus Brachioradialis Elbow & Forearm - Actions Elbow & Forearm - Nerves Assessment - Observations Carrying angle as expected in anatomical position Men: 5-10 degrees Women: 10-15 degrees Cubitus valgus > 15 degrees (greatest in extension) Cubitus varus < 5-10 degrees Fracture Supracondylar (humeral) malunion results in varus angulation called Gunstock deformity Radial head: common MOI: FOOSH pain and tenderness along lateral aspect of elbow limited elbow or forearm motion Immobilization required  so ROM rehab may be needed Surgery  ORIF Dislocation/Subluxation Radial Head Subluxation (Nursemaid’s elbow) MOI: Occurs in toddlers when a traction force is applied to the forearm, e.g. adult catching a fall by grabbing wrist Causes pain & child will not move elbow In adulthood the radial head is wider than the radial but in toddlers its about the same size so it slips thru the ligaments on the neck Lateral Epicondylitis (Tennis Elbow) Tendinitis at common origin of the wrist extensors i.e. lateral epicondyle of humerus Dull ache at rest; sharp pain with activity Gradual onset usually involving repetitive wrist extension. Treatment: conservative but in some cases Sx Medial Epicondylitis (Golfer’s elbow) Tendinitis (inflammation) at common origin of wrist flexors i.e. the lateral epicondyle of humerus Pain on the medial aspect of the elbow, pain or weakness with gripping, twisting and lifting Treatment: conservative but in some cases Sx Pronator Teres Syndrome Compression neuropathy of the median nerve at the elbow by pronator teres Parasthesia in thumb, index finger, middle finger which is aggravated with activity Pain on the volar aspect of the forearm. Cubital Tunnel Syndrome Numbness and tingling in ring and small fingers Increased pressure and tension on the ulnar nerve with elbow in a flexed position Ulnar Collateral Ligament Pathology Inflammation, stretch or tear to UCL caused by repetitive overhead motion or FOOSH  E.g. Baseball pitchers Leads to pain & instability Special Tests – Neuro Dysfunction Tinel’s Sign at Elbow: tap nerve in ulnar groove +ve: tingling in ulnar n. distribution (distal to lesion/compression) Test for Pronator teres Syndrome: Pt. in sitting with elbow flexed to 90. Therapist provides strong resitstance to pronation while elbow is extended +ve:tingling/parasthesia in median. distribution Elbow Flexion Test (for cubital tunnel syndrome): Instruct Pt to to fully flex elbow while in wrist extension & shoulder abduction. Hold position 3-5 min. +ve: tingling/parasthesia in ulnar n. distribution Special Tests – Epicondylitis Lateral Stabilize elbow and while palpating epicondyle with thumb ask the Pt to perform full fist with pronation, radial deviation & wrist extension; therapist resists. +ve: sudden significant pain elicited at epicondyle Medial Passively supinate the forearm while extending the wrist and palpating the epicondyle +ve: pain elicited OT Interventions Education Donning & doffing sling/brace Therapeutic exercise e.g. pendular exercises ADLs Home supports