1
Q
Lateral/anterior shoulder pain with overhead activities or exhibits a painful arc think what 3 pathologies
A
Subacromial impingement
Tendinitis
Bursitis
2
Q
Instability, apprehension, and pain with activities, most often when shoulder is abducted and externally rotated, think, what 2 conditions
A
Shoulder instability
Possible labral tear if clicking is present
3
Q
Decreased ROM and pain with resistance, think what 2 conditions
A
Rotator cuff
Long head of the biceps tendinitis
4
Q
Pain and weakness with muscle loading, night pain; Age >60, think
A
RC tear
5
Q
Poorly located shoulder pain with occasional radiation into elbow; Pain is usually aggravated by movement and relieved by rest; Age > 45; Females > Males, think
A
adhesive capsulitis
6
Q
falling on the shoulder itself as an MOI, think
A
AC joint sprain
7
Q
Upper extremity heaviness or numbness with prolonged postures and when lying on involved side, think
A
TOS
Vertebral radiculopathy
8
Q
one non MSK pathology that would work for R and L side
A
MI
9
Q
capsular pattern for GH joint
A
ER > abduction > IR > flexion
10
Q
capsular pattern for other shoulder joints
A
px with extreme motions
11
Q
when looking at posture, if there is an increased clavicular angle, this could indicate
A
tight upper trap
12
Q
when looking at posture, if there is a depressed clavicular angle, suspect
A
lengthened upper trap
13
Q
the spine of the scapula should be at level
A
T3
14
Q
scapula lower on one side could indicate
A
- Hand dominance
- Long upper trap
- Tight latissimus
15
Q
elevated scap could indicate
A
- Tight upper trap/levator scapulae
- Long lower trap
16
Q
abd scap could indicate
A
- Tight serratus anterior, pectoralis major
- Long mid trap, rhomboids
17
Q
adducted scap could indicate
A
- Tight mid trap, rhomboids
- Long pectoralis major, serratus anterior
18
Q
what is ant tilted scap
A
inf angle lifted off
19
Q
what could causes of ant tilt scap be
A
- Tight pec minor
- Weak lower trap
20
Q
upwardly rotated scap might indicate
A
- Tight upper trap
- Weak rhomboids, levator scapulae
21
Q
downwardly rotated scap might indicate
A
- Tight rhomboids, levator scapulae
- Weak upper/lower trap
22
Q
when you observe gross shoulder flexion, look for
A
• Pain
• 2:1 ratio humeral/scapular rhythm
• Symmetry in glenohumeral creases
- Deeper – not get enough inferior glide humerus
• End with 60⁰ scapular upward rotation
• Winging (with flexion and/or return from flexion)
• Appropriate scapular elevation
• Humeral position at end: medial or lateral rotation
• Minimal movement of spine
23
Q
when you observe gross lateral rotation of shoulder at 90/90 look for
A
- Scapula should not adduct during first 35 degrees motion
- Humerus should rotate along vertical axis
- Humeral head should be stable
24
Q
main axns of upper trap and levator scap
A
elevate shoulders
25
main axn of middle trap
straight adduction of scap
26
axn of lower trap
adduction and depression of scap
27
main axn of rhomboids
retraction
| DR
28
ant deltoids axn
main is flexion
29
coracobrachialis
flexion and adduction of shoulder
30
pec major
hor. adduction with some IR
31
supraspinatus
abd and ER
32
mid delts
abd
33
post delts
extension
34
shoulder extensors
Lats, teres major, post delt
35
main ER of shoulder
Infraspinatus, teres minor
36
IR of shoulder
Subscap, teres maj, lat dorsi, pec major
37
apley's scratch test is for
general screen of ROM (reach over then under)
38
differentiating btwn supraspinatus and deltoid when doing resisted testing (other than location of px)
supraspinatus would not hurt with flexion and ext like the delt would
39
axns of teres major
adduction and medial rotation
40
subscap
IR only
41
capsular special tests (or instability tests)
```
All (apprehensive)
Roads (relocation)
Lead (load and shift)
to
Sulcus (sulcus)
```
42
explain the apprehension test
they are supine, really you just ER shoulder and watch for apprehension or px
43
what is relocation test
you do it after the apprehension test
supine, you push the capsule post first, if they report no px or say that feels better...then push the capsule ant and that should cause sx
44
explain load and shift test
pt is seated
| you apply superior load and then push shoulder ant and post
45
sulcus sign grading scale
```
1+ = 0.5-1 cm
2+ = 1-2 cm
3+ = 2-3 cm or more 9
```
46
list the labrum/articulating surfaces tests
```
crank
clunk
quadrant
obriens
yergasons
(crazy carl quietly overcame you)
```
47
explain the crank test
they are supine with arm at angle, elbow bent
| apply load and fully ER and IR (no ant shift of humeral head)
48
explain clunk test
supine, elbow at 90 degrees, one hand on post aspect of their capsule, one hand at elbow. Do a slight ant glide (push forward) as you axial load to the body and push the elbow up to face and then full ER.
49
explain quadrant test
Supine again – 90 degrees, start in ER, do ant glide again,
| elbow below head of humerus, axial load and just take forearm to head
50
explain pos findings for obriens
if pain is reported with resistance in the IR position, but lessens or disappears in the ER position. If superficial joint pain occurs, consider AC joint pathology
51
explain obriens test
```
seated
slight adduction of shoulder
full pronation first and resist
then full supination and resist
(if px is only felt pronation = pos)
```
52
explain yergasons test
yurgonna try to put them in pronation
they are seated, elbow at 90
you are trying to push them into pronation
53
List the tests for RC tear
```
Drop arm
Lift off
Supraspinatus
Lag sign (ER)
Cross over
Speeds
D L S L C S (dudes like single ladies cup sizes)
```
54
explain the drop arm test
they are standing
abd the arm with pronation
have them hold it and then they slowly lower
can they hold it up
55
explain the lift off test
arrested position
| first AROM then resisted
56
pos lift off could indicate
subscapularis tear; pain in front of shoulder
biceps tendonopathy; difficulty holding against resistance
subscapularis tendonopathy; px during mvmt
57
explain supraspinatus test
full can test
scapular plane
thumb up and resist
58
explain lag sign
pt is seated
you place them in scap plane, then ER their upper arm and ask them to hold there
(pos is supra or infraspinatus)
59
explain cross over test
pt is seated as you essentially do a cross the body stretch
60
pos findings for cross over test
If pain is anterior = Subscapularis, Supraspinatus and long head of Biceps
If pain is superior = implicates the AC joint
If pain is posterior = implicates the Infraspinatus, Teres Minor, and/or the posterior capsule.
61
speeds tests for __ or __
SLAP or biceps
62
explain speeds
straight flexion as you resist (palm up)
63
for yergasons test, they are palm __
down
64
the "pseudojoint" of the shoulder region
scapula and thorax
65
issue with size of structures in shoulder joint
glenoid fossa is smaller than head of humerus
66
lateral portion of biceps tendon anchors to the
labrum
67
the post capsule is under stress in what positions
Under tension when shoulder in flexion, adduction, and/or IR
68
the superior GHL is under stress in what positions
Under tension with shoulder in adduction, inferior and posterior translation of humerus
69
the middle GHL is under stress in what positions (and resists what motion)
Under tension with shoulder in ER, resists anterior translation
70
which lig is the Primary restraint against anterior and posterior dislocations
Inf GHL
71
list all structures in the suprahumeral space
```
Long head of biceps tendon
Superior joint capsule
Supraspinatus
Upper margins subscapularis and infraspinatus
Subacromial bursa
```
72
open packed position GH joint (AKA RESTING)
55 degrees abduction
30 degrees horizontal adduction
Neutral rotation
73
closed packed GH
ER, ABD
74
what role does AC joint play in elevation
Must rotate approximately 40-50 degrees for full elevation to occur
If not, elevation limited to ~110 degrees
75
ac joint and sc joint open packed position
arm at side
76
the sc joint is really for
stabalization
77
during arm elevation, the scapula should do what motions
60 degrees upward rotation,
15-25 degrees ER,
15-30 degrees posterior tilt
78
SC only has a ____ position
open packed (arm at side) does not have closed pack or capsular pattern
79
biomechanics of 0-90 elevation
Supraspinatus contracts to initiate abduction (depresses and stabilizes head in glenoid fossa)
Remaining rotator cuff muscles contract to pull the humeral head into the glenoid fossa
Around 20-30 degrees, scapular upward rotation begins with concurrent clavicular elevation and axial rotation
At 90 degrees (approx) upper extreme of GH abduction is reached and clavicular elevation ceases due to tension of costoclavicular ligament
At this point scapula has rotated upwardly around 30 degrees
80
biomechanics of end range elevation (90 - 150)
Scapula upwardly rotates about 60 degrees, with scapular contribution peaking between 90-140 degrees
~ 120 degrees of humeral elevation
~ 75 degrees of GH external rotation needed
Upward rotation accommodated at SC and AC by 30-40 degrees of posterior clavicular axial rotation and clavicular elevation of 30-36 degrees
81
biomechanics of 150 -180 elevation
Abduction beyond 150 requires adequate motion of upper thorax and cervical spine, while bilateral abduction requires thoracic extension and increase in lumbar lordosis
82
why is scapular plane ex a good idea
Length-tension relationship of RC muscles is ideal
Movement of the humerus is less limiting because GH capsule is not twisted
Mechanical axis of GH joint is in line with mechanical axis of scapula
83
Usually see more _____ changes in the tissues surrounding the glenohumeral joint
degenerative
84
restriction in AROM and PROM is
adhesive capsulitis or frozen shoulder
85
associative factors of adhesive capsulitis
```
Female
> 40 y/o
Trauma
Diabetes
Prolonged immobilization
Thyroid disease
Stroke or MI
Presence of autoimmune diseases
```
86
explain adhesive capsulitis
there is thickening of the tissue, adhesions are made which ends up limiting all motions
87
what can lead to adhesive capsulitis
arm injuries that end up restricting shoulder motion= adhesions
they end up with synovial inflammation
88
stages of adhesive capsulitis
Stage 1: Mild signs and symptoms
89
what motions are lost in stage one of adh cap
Capsular pattern of motion (loss ER and abduction) present, described as achy at rest and sharp at extremes of ROM, pain palpation anterior and posterior capsules, pain radiates to deltoid insertion
90
what motions are lost at stage 2 adh cap (and sx)
Pain palpation anterior and posterior capsules, pain radiates to deltoid insertion, loss of motion in all planes, pain in all parts of the range
91
stage 3 adh cap manifests how
Often report painful phase that has resolved but continue to have stiff shoulder, poor scapulohunmeral rhythm during arm elevation, dominance upper trapezius, decreased inferior glide of the GH joint
92
main feature of stage 4 ad cap
capsular end feel is reached before pt reports px
93
which phase of healing do you really want to get more aggressive with adh cap
subacute
94
most unstable direction is ___, this is where most dislocations happen
ant
95
avulsion of the anterior inferior labrum from the glenoid rim, can lead to instability (lower labrum)
bankhart lesion
96
compression fracture of the posterior humeral head at the site where the humeral head impacted the inferior glenoid rim
Posterior humeral head rub on the glenoid when it subluxes anteriorly inferiorly
hillsacs lesion = can lead to instability
97
most common c/o is px, Pain with overhead movements due to inability to control their laxity
Symptoms occur in abducted and ER position. hx of swimming or repetetive mvmt that puts stress ...think
instability
98
what assessment must you perform if you suspect instability
joint mob assessment
99
working on ____ and avoiding ____ and ___ motions is important with instability
```
stabalizing structures (RC, scapula)
avoid ER and abd
```
100
a bankhart tear is associated with ___ dislocation
ant
101
what is torn in an bankhart tear
inf GHL
102
what motion is often lost after a bankhart repair
some ER
103
why is ER lost after bankhart repair
bc they have to attach the subscap and labrum to the glenoid cavity
104
what pathology is often associated with GIRD
SLAP
105
what constitutes GIRD
Loss of IR and total ROM loss
106
common MOI for SLAP lesions
FOOSH – fall on outstretched hand
| Forceful biceps contraction (catch heavy weight)
107
5 tests for SLAP
```
Y O C L S
O’Brien test
Clunk test/ Crank test
Yergason’s test
Load and shift test – for instability asssoc with SLAP
Speeds
```
108
which types of AC joint sprain is associated with a fall or blow to lateral shoulder
I
| II
109
which types of AC joint sprain are associated with dislocation
III
| IV
110
what test is good for AC joint sprain
crossover
111
how to differentiate btwn tendonitis and a tear
tendonitis usually improves after 3 weeks
| also, tedonitis can achieve full ROM
112
a clearly pos drop arm test would indicate
possible full thickness tear
113
a clearly pos supraspinatus test would indicate
partial tear
114
why is it important to get RC surgery if torn
it can end up limiting the sup space in the capsule as the humerus glides sup
115
what is primary impingement
intrinsic degenerative process in the structures occupying the subacromial space,
anterior impingement
Intrinsic degenerative process in structures in subacromial space
Typically >40 y/o
Hypomobility may be associated
Occurs when superior aspect of RC is compressed and abraded by surrounding bony and soft tissues
116
what is secondary impingement
lesser tuberosity of the humerus encroaches on the coracoid process
cause: GH instability or poor control of humeral head in overhead activities, hypermobility may be associated
Have a history of traumatic instability, labrum damage and/or posterior defect humeral head
Alters PICR, humerus migrates too superior
117
impingment usually causes px with
overhead activity
118
signs of secondary impingement
Limited IR
Excessive ER
Antero-superior humeral head migration
119
the ___ joint is most common one in shoulder for arthritis
AC
120
types of shoulder replacement
total- both are new
hemi- only humerus part is new
reverse- humerus is cave, glenoid is vex
121
3 big causers of bursitis
infection
injury
calcifications
122
test for bursitis
neer
123
differentiating btwn bursitis and tendonitis
if they cant reach overhead - bursitis (pts with bursitis literally cannot reach overhead)
124
most common fx bone in children
clavicle
125
tell of clavicular fx
cant elevate past 60
126
causes of brachial plexus injury
```
Entrapment from “cervical rib”
Stretch injury
Radiation
Clavicular fractures
Compression by soft tissue
```
127
causes of TOS
Caused by compression of tight muscles (eg scalenes, pec minor) or clavicle and first rib
128
TOS has a ___ component (different than brachial plexus)
bv
129
2 common peripherial nerves that can be injured
axillary - delt
| radial
130
stages of RSD
I (acute): burning pain, tenderness, swelling, vasomotor changes
II: persistent aching, swelling w/ hardening, skin/nail bed changes
III: skin and subcutaneous strophy, development contractures
131
RSD is associated with
neuro trauma
132
sx of RDS
```
Discoloration
Hypersensitivity of skin
Moist skin
Chronic edema
Atrophy
Weaknes
```
133
AC joint sprain 4-6's they will do
surgery (1 -3 don't)
134
with tendonitis you HAVE FULL ROM but it's just, with a tear you dont have ____
pxful
| ROM
135
if supraspinatus is injured, how does this effect delt
If supraspinatus is injured, the deltoid kicks in – but the movement of humeral head isn’t as efficient…..so when deltoid is dominant the humerus will glide superiorly instead of the supraspinatus controlling the motion from the top, the deltoid tries to control the motion from the bottom.
136
How will you tell diff btwn primary and secondary impingement –
primary impingement is hypomobile –deg changes
secondary impingement is associated with hypermobility or instability.
do mob assessment to see
137
weird tx for calcification with bursitis
ionto with vinegar
138
precursor for any bursitis
RA or autoimmune
139
injuries caused by foosh (4)
clavicle fx,
SLAP lesion,
proximal humerus fx,
RC tear
140
3 pathologies with pxful arc
bursitis, RC, impingement
141
how can you differentiate btwn TOS and RSD
Complex regional px syndrome – px is out of proportion to injury
TOS is more “typical” neuro sx.
What is same about the conditions: both can have BV issues
RSD or complex regional px syndrome happens after trauma, usually the distal extremeties are effected first
142
pathologies associated with scap downward rotation syndrome
```
• impingement
• Thoracic outlet syndrome (TOS)
• Instability
• Rotator cuff
tendinopathy/tear
• Nerve injury
• Bursitis
```
T I T I R B N
143
explain scapular downward rotation syndrome
in resting, scap is "stuck" in DR
| very limited UR occurs during AROM
144
what is probably to tight in scapular downward rotation syndrome
dominant: rhomboids, levator scap, pecs, lats
145
what is probably weak with scapular DR syndrome
weak serr ant and weak traps
146
WHAT IS PROB DOMINANT IN SCAP DEPRESSION SYNDROME
LATS
PECS
LOWER TRAP
147
pathologies asst with depression syndrome
```
• impingement
• Thoracic outlet syndrome (TOS)
• Upper trap strain
• Rotator cuff tendinopathy/tear
• Neck pain
IN RUT
```
148
SCAPULAR DEPRESSORS
latissimus, pectoral muscles, and lower trap
149
SCAPULAR ELEVATORS
upper trap and levator scapulae
150
2 muscles that abd the scap
serratus ant and pec major
151
scapular adductors
rhomboids
| mid traps
152
WHAT IS A TELL OF SCAP DEPRESSION SYNDROME
THE SCAP ITSELF WILL BE LOWER THAN T2-T7
| OR SPINE IS LOWER THAN T 3
153
SCAP ABDUCTION SYNDROME HAS WHAT RYTHYM
1:1
154
SCAP ABDUCTION SYNDROME PRESENTS HOW
THE SCAP IS PROTRUDING LATERALLY
155
WHICH OF THE ACROMION TYPES IS THE MOST CURVED
III
156
DIFF BTWN SUPRA AND DELTS
DELT INVOLVES FLEXION OR EXT TOO
157
TERES MAJOR
ADDUCTION AND IR
158
ANYTIME THERE ARE GH MOB ISSUES YOU ALWAYS LOOK AT ___ FIRST
SCAPULA
159
EXPLAIN THE MOB ASSESSMENT OR PAM ASSESSMENT PRIOR TO MOBS
Assess distraction, inferior glide, posterior glide and anterior glide.
160
INF SHOULDER GLIDE FACILITATES
• Facilitates abduction and flexion
161
POST GLIDE OF SHOULDER FACILITATES
• Facilitates medial rotation, flexion, horizontal adduction
162
POST GLIDES AT END RANGE, YOU WILL PROB USE WHAT GRADES
3, 4, 5
163
ANT SHOULDER GLIDES FACILITATE
• Facilitates lateral rotation, extension, and horizontal abduction
164
STERNOCLAVICULAR JOINT MOB RULES
it is a convex surface moving on a concave surface for elevation/depression (SUP AND INF GLIDES)
and it is a concave surface moving on a convex surface for protraction/retraction. (DORSAL AND VENTRAL GLIDES OR ANT POST)
165
CAUDAL IS AKA
INF
166
POST STERNOCLAVICULAR GLIDES FACILITATE
Facilitates retraction/horizontal abduction.
167
ANT SC GLIDES FACILTATE
PROTRACTION
168
SC JOINT MOB, INF GLIDE FACILITATES
ELEVATION OF SHOULDER
169
TO TEST AC JOINT, STABALIZE THE AC AND MOVE THE
CLAVICLE
170
ALL AC MOBS FACILITATE
ELEVATION
171
WHICH SC GLIDE DO YOU PUSH THE STERNUM POST
ANT GLIDE
172
NORMAL CARRYING ANGLE
5º-15º in men; 15º-20º in women.
173
IF OLECRANON FACES LATERALLY, THEN THE ARM IS REALLY IN ___ ROTATION
INTERNAL
174
WHEN INF ANGLE OF SCAP IS LOCATED MORE LATERALLY
UR SCAP
175
FORWARD HEAD INDICATES SHORT ___ AND LONG __
SHORT EXT LENGHTENED NECK FLEXORS
176
WHEN DOING ER, SCAP SHOULD NOT ADDUCT WITHIN THE FIRST ___ DEGREES
35
177
AT END RANGE SHOULDER FLEXION, SCAP SHOULD BE UR __ DEG
60
178
All SC glides are ____ of what you think makes sense
opp
179
which SC glide is the one you press on the sternum
for ant glide you push the sternum post-this aids in protraction
180
normal shoulder flexion
165
181
normal shoulder ext
60
182
normal shoulder ABD
165
183
normal shoulder add
40
184
normal shoulder ER
90
185
normal shoulder IR
70
186
Strong and painless:
not muscle
187
Strong and painful:
muscle
188
Weak and painless:
neuro issue
189
adhesive capsulitis will usually show what "tell" sx
loss of PROM in capsular pattern (especially ER and ABD)
190
what 2 systemic pathologies are pts at risk for adhesive capsulitis
diabetes and thyroid issues
191
what 3 outcome measures are good for adhesive capusulitis
DASH (disability arm shoulder hand)
ASES (american shoulder and elbow surgeons)
SPADI (shoulder pain and disabilty index)
192
List all outcome measures for arm/shoulder
```
UEFI (upper ext functional index)
DASH
Quik DASH
SPADI
ASES
```
193
which of the outcome measures are lower score is worse
UEFI
| ASES
194
Which of the outcome measures is higher score is worse
DASH
Quick DASH
SPADI
195
best tx for adhesive cap
steroid shots
mobs
stretching
196
dull ache is associated with what 3 pathologies
RC
AD Cap
Bursitis
197
anterior shoulder px is associated with
Impingement
198
rapid onset after activity is what pathology
bursitis
199
px at end range of crossing arm over body is what pathology
AC
200
impingement usually comes about due to
repetetive motions (ex swimming)
201
recent clavicle fx, and now px with tingling....think what pathology
TOS
202
is PROM effected (in the direction of the normal muscle motion) with muscle pathologies
no
| PROM would only cause sx when you go in the opposing direction (stretching)
203
impingement has what 2 motions limited
hor abd
| IR
204
reveresed scap/humeral rythym with dominent delts, think
RC
205
what is considered pos for the lat length test
if the second measurement (elbows bent hands towards head) is smaller than reg shoulder ROM then the lats are short
206
what do you have to do for any scap mobing
give them a pillow in front of their body
207
what do you have to do for any SC mobing
give them a pillow to hold at chest
208
explain ant GH glide
hamburger grip as they are supine
MSK
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