1
Q
Capsular Pattern: Glenohumeral Joint
A
SLAM
Shoulder: Lateral Rotation > Abduction > Medial Rotation
Loss of movement
2
Q
Resting (loose pack) Positon: GHJ
A
- 30 Flexion
- 30 Abduction
- Slight IR
3
Q
Thoracic Outlet Syndrome
Description & Border & Contains
A
The area along the brachial plexus between the nerve roots & lower border of the axilla
Borders:
- ANTERIOR: clavicle, coracoid process, pec minor
- POSTERIOR: Upper Fibers of Traps (UFT), scapula
- MEDIAL: scalene mm & R1(first rib - behind clavicle)
- LATERAL: axilla
Contains:
- Brachial Plexus
- Subclavian artery
- Subclavian vein
Starts outside medial border (infront of scalenes) & passes infront of rib 1 && then joins the other outlet
4
Q
Thoracic Outlet Syndrome
Description & Types
A
A term used to describe a group of signs & symptoms resulting from compression of nerves or vascular structures in the thoracic outlet
Diagnosis of exclusion - tends to be overdiagnosed
Types:
1. Neurogenic (True TOS)
2. Nonspecific “symptomatic” neurogenic
3. Vascular syndromes - arterial
4. Vascular syndromes - venous
5
Q
Neurogenic (true TOS)
2
A
Patient presents with an anatomical anomaly compressing the brachial plexus (cervical rib - extra, or elongated C7 TP)
True TOS is rare
6
Q
Nonspecfic “Symptomatic” Neurogenic
4
A
Most common
- Signs & symptoms similar to true TOS but there is no evidence of anatomical anomalies, mm atrophy, or EMG findings suggesting TOS.
- Diagnosis based solely on S/S & exclusion of competing diagnosis
- Typically, d/t to maladaptive posture. Related to adaptive shortening of sclene mm & pec minor (shortening of mm)
- Most TOS complaints fall under this subtype
7
Q
Vascular - arterial
3
A
- Compression of subclavian artery
- Typically, d/t anatomical anomaly (ie cervical rib)
- Typically, aggravated by arm motion, especially overhead activity
8
Q
Vascular - venous
2
A
- Compression of subclavian vein does not typically result in TOS complaints
- Typically, as a result of another cause (thrombosis)
9
Q
TOS S/S
3 Types (4 + 5 + 2)
A
Neurogenic
1. Paresthesia
2. Numbness
3. Weak grip strength (?atrophy of thenar)
4. Loss of manual dexterity & precision movements in hand
Vascular - Aterial:
1. Cool skin
2. Pale extremity (BF interruptions)
3. Dimished or absent pulse
4. Rapid fatigue of limb
5. Lower BP on the affected side
Vascular - Venous:
1. Painful swelling in arm
2. Mottled, bluish discolouration
10
Q
TOS: Epidemiology
(5)
A
- F>M (neurological TOS)
- Typically occurs b/t 20-50 years of age
- Neurological symtpoms more common > vascular
- Commonly involves lower roots of brachial plexus (C8-T1)
Ulnar Distributions - Commonly seen in athletes, occupations, & sports that involve extreme ranges of abduction & ER
11
Q
TOS: Etiology
(9)
A
- Congenital anatomical anomaly (ie cervical rib)
- Muscle hypertrophy of scalenes mm, subclaviusm or pec minor (APICAL breathing)
- Inflammation or scar tissue formation in structures surrounding brachial plexus (occupying space)
- Traumatic (ie clavicle #, WAD causing scalene spasm)
- Posture (adaptive shortening of scalene & pec minor mm)
- Pressure (ie bra strap, bookbag, shoulder purse)
Bra strap: broad > thin = distributes forces - Excessive overhead activities
- Thrombus (vascular - venous TOS)
- Pancoast tumor - occupy an area (associated w/ horners syndrome)
12
Q
TOS: Classifications
(4)
A
Scalenus Anterior Syndrome
- Site of compression: Interscalene triangle - b/t the scalenus anterior & medius (supraclavicular)
Costoclavicular Syndrome
- Site of compression: Costoclavicular space - b/t the clavicle & first rib (subclavicular)
Hyperabduction Syndrome
- Site of compression: Axillary interval: Under the coracoid process & behind the pec minor (infraclavicular)
Cervical Rib Syndrome
13
Q
Special Tests:
Adson Manuever
Costoclavicular Syndrome (Military Brace) Test
Halstead Manuever
Wright Test
Allen Test
A
All tests palpate RADIAL pulse in different postures
(+) = if radial pulse dissapears
Aterial type TOS
14
Q
Special Test: Roos Test (Elevated Arm Stress Test)
A
Procedure:
PT open & closes fists with shoulder (horizontal abduction) & elbow at 90 degrees for 3 minutes
(+) = inability to hold position for 3 mins
- Ischemic pain - arterial
- Heaviness/weakness = arterial
- S/S of neurological weakness - ex. numbness & tingling
15
Q
Special Test: Shoulder Girdle Passive Elevation (Cyriax Release Test)
A
Procedure:
- Pt crosses arms & PT lifts elbows up - elevation
(+) = relieves neurological S/S
- Skin colour changes / temp - arterial
- Pulse becomes stronger
- Less cyanotic - venous
Cyriax = switch arm positions: pt has elbows @ 90 & pronated & PT lifts the arms this way
16
Q
Cross Body (Horizontal) Adduction Test
A
Shoulder Separation
- The test is performed by passively bringing the patient’s arm into 90 degrees of forward flexion, with their elbow also flexed to 90 degrees.
- The examiner then horizontally adducts the flexed arm across the patient’s body, bringing their elbow towards the contralateral shoulder
(+) = if the maneuver successfully reproduces the patient’s symptoms of pain localized over the AC joint
17
Q
Shoulder Separation
Definition & Etiology
A
Trauma to the ligaments holding the acromion and clavicle togeter causing separation b/t the 2 joint surfaces (subluxation or dislocation)
Etiology
1. Downward force on the acromion
2. Directly falling on or hitting the acromion
3. Falling on outstretched hand or falling on elbow
18
Q
Shoulder Separation: S/S
(3)
A
- Step deformity (clavicle is no longer attached & clavicle sticks up)
Distal end of clavicle sticking up
Grade 3 sprain: Both acromioclavicular & coracoclavicular ligaments have been torn
Deltoid & trapezius mm may be torn from distal end of clavicle - Tenderness & swelling over ACJ
- Pain with shoulder horizontal adduction (compressing joint together), elevation (Flex or abd - clavicle posterior roll), and HBB (hurts b/c of EXT & clavicle move - Anterior roll)
19
Q
Shoulder Separation: Special Test
1
A
Cross Body (Horizontal) Adduction Test
20
Q
Shoulder Separation: Radiology
1
A
Stress-view X-Ray:
- Patient hold weight onto each arm - longitudinal traction
- Places an inferior pressure on ACJ
21
Q
Shoulder Separation: Rockword Classification
3
A
Type I: Sprain
- Capsule is intact
- No separation or excessive spacing is seen
Type II: Subluxation
- Increased ACJ spacing
Type III: Dislocation
- Increased ACJ & costoclavicular space - completely dislocates
- Joint surfaces not in contact with each
22
Q
Glenohumeral Joint Instability: Classifications
4
A
- Direction
Anterior, posterior, inferior, multidirectional - Degree
Subluxation (partially out), dislocation (out of socket) - Etiology
Traumatic, atraumatic - multidirectional instability - Timing
Acute, recurrent
23
Q
Shoulder Dislocation
3
A
Separation of the humerus from the scapula
Most commonly dislocated joint in the body - very mobile - many degrees of freedom
Anterior dislocation is the most common = orthopedic population
Inferior dislocation = stroke population
24
Q
Shoulder Dislocation: Epidemiology
(2)
A
- M>F
- Typically seen in patients <30 years of age - younger ppl d/t the activities they do
25
Shoulder Dislocation: Etiology
| 2 Types (3 + 1)
**Traumatic**
- Direct trauma to humeral head
- Indirect trauma (forced ROM) - key locked position in BJJ
- Most commonly while in **abduction & ER** = dislocate anteriorly
Stability in this position provided by **subscapularis, GH ligaments** (especially anterior band of the inferior ligament), and **long head of biceps**
**ANTERIOR dislocations** may damage the subscapularis, long head of biceps, GH ligaments, anterior capsule, and anterior glenoid labrum
**Atraumatic**
- General laxity in shoulder causes shoulder to become unstable - HYPER mobile
26
Shoulder Dislocation: S/S
| (8)
1. Feeling of slippage with pain
2. Feeling of insecurity w/ specific activities
3. **Possible pain or apprehension when approaching extreme ROM**
4. DEC ROM during acute phase due to apprehension
5. INC ROM during chronic phase due to instability - hypermobility into the range d/t stretching of the structures
6. May appear normal on clinical examination, may become more apparent after repeated activity when fatigue sets in
Fatigue = start to experience pain / slippage - clinical tests. Tx like an instability
7. Possible atrophy on affected side due to disuse (chronic)
8. Sulcus sign may be present
27
Shoulder Dislocation: Potential Complications
| (5)
1. Axillary nerve damage
- Must check for axillary nerve damage prior to reducing a subluxed or dislocated shoulder
- Check by testing the nerves they innervate (MMT) = deltoid, teres minor
2. Axillary artery
- May be damaged with injury or reduction
3. Brachial Plexus
- Less commonly damaged, may occur to other branches of the brachial plexus, of which the **posterior cord is most common**
4. Bankart Lesion
- Most **anterior dislocations** damage the labrum
5. Hill-Sach's lesion
- Posterolateral humeral head compression (indentation) fracture (Hill-Sach's lesion) may occur secondary to anterior shoulder dislocation d/t forceful impaction of the humeral head against the anteroinferior glenoid rim
- Indentation - dent = compression #
28
Spectrum of Instabilty
| 2 Types
AMBRI > TUBS
AMBRI - "Born Loose"
- **Atraumatic** etiology, **Mutli-directional** w/ **Bilateral** shoulder findings with **Rehabilitation** as treatment choice, & rarely **Inferior** capsule shift surgery is required
TUBS - "Torn Loose"
- **Traumatic** onset, **Unidirectional** anterior with a **Bankkart** lesion responding to **Surgery**
29
Special Test:
Crank (apprehension) & relocation test
Apprehension release (suprise) test
Load & shift test
Anterior Instability
30
Special Test:
Jerk Test
Load & shift test
Posterior Apprehension
Posterior Instability
31
Suclus sign
Feagin Test
Inferior & multidirectional instability
32
Glenohumeral Labral Tear:
| Description & Types
A tear in the labrum of the glenoid fossa
Types:
1. Bankart - Reverse Bankart (same but posterior - posterior dislocation)
2. SLAP
33
Glenohumeral Labral Tear:
Bankart
| Description & Etiology & S/S
Anterior inferior tear of the labrum (**3-7 o'clock)
Etiology:
- Commonly occurs with antertior dislocation of GH joint
- Common in overhead sports & occupational activities
S/S:
1. Sensation of clicking &/or popping w/ movement
2. Diffuse shoulder pain
3. Worse w/ HBB
4. Feeling of weakness & instability
34
Glenohumeral Labral Tear:
SLAP
| Description & Etiology & S/S
Superior Labrum Anterior & Posterior (**10-2 o'clock**)
- Long head of biceps inserts directly into superior labrum > LHB may pull forcefully & detach causing a SLAP lesion tear > if LHB becomes detached, shoulder becomes unstable
*ECCENTRIC force*
Etiology:
- Repetitive throwing & overhead activities
- Deceleration when throwing
- Direct trauma
- FOOSH (w/ shoulder abduction & slight forward flexion)
- Traction injury (to biceps) in inferior direction
S/S:
1. Sensation of clicking &/or popping with movement
2. GIRD - Glenohumeral INTERNAL rotation deficiency
*DEC ROM in IR - affected vs unaffected*
3. Pain w/ overhead activity (elevation) & lying on unaffected side (?night pain - related to lying on it)
4. Loss of strength & endurance in rotator cuff & scapular stabilizer mm
5. "Dead arm" syndrome in pitchers - prainful & lower velocity
35
Special Test:
Clunk Test
Active Compression Test of O'Brien (specifc to..)
Biceps Load Test (Kim Test II)
Glenohumeral Labral Tear
Active Compression Test of O'Brien - specific to SLAP tear
36
Adhesive Capsulitis
| Decription & Epidemiology & Etiology
An idiopathic condition which is characterized by shoulder pain followed by progressive loss of glenohumeral joint (GHJ) ROM following a capsular pattern d/t the development of dense adhensions & capsular thickening surrounding the GHJ
- Shoulder pain > shoulder DEC ROM > capsular pattern loss (ER > Abd > IR)
Epidemiology:
- F>M
- Typical age of onset between 40-60 years old
- More common in **non-dominant** shoulder
- INC incidents in diabetes
Etiology:
1. Primary adhesive capsulitis: Idiopathic
2. Secondary adhesive capsulitis: secondary to other conditions which there is shoulder pain &/or restricted ROM may lead into adhesive capsulitis
Ie. trauma, immobilization (clinical relevant - need to encourage mvmt post-op), surgery, recent stroke, recent MI, thyroid disease, DM, OA, RA
3. Adhesive capsulitis has a high correlation w/ psychosocial issues (anxiety, stress)
37
Adhesive Capsulitis: S/S
| (6)
1. Progressive GHJ ROM restrictions
2. ROM restriction follows a capsular pattern of the shoulder (ER>ABD>IR)
3. Difficulty w/ HBB, HBH, & overhead activities (activity & functional limitations)
4. Reverse scapulo-humeral rhythm present with increasing GHJ ROM restrictions
*Normal (2:1) - reverse in frozen shoulder - more mvmt w/ scapula. Compensations: shoulder hike)
5. May present with trick movements during examination (ABD - side bending)
6. General mm weakness & poor endurance may be present
38
Adhesive Capsulitis:
Stages
| (4)
Stage 1:
- Gradual onset of pain
- Increases w/ mvmt & present at night
- Loss of ER ROM w/ intact rotator cuff strength
- Duration **< 3 months**
Stage 2: "Freezing"
- Persistent & more intense pain, even at rest (dull & achy)
- Restricted ROM in all directions (capsular pattern)
- Duration: **3-9 months**
Stage 3: "Frozen"
- Pain only with mvmt. Less night pain
- Significant adhensions. **HARD capsular end feel in most directions**
- Restricted ROM in all directions w/ increased scapula compensation mvmts
- May present with atrophy of deltoid, rotator cuff, biceps & triceps
- Duration: **9-15 months**
Stage 4: "Thawing"
- Minimal pain
- Significant capsular restrictions at start of this stage, but gradual return of ROM
- Some patients may never regain full ROM
- Duration: **15-24 months or longer**
As a whole, frozen shoulder takes approx ~2 years to run its course & is also SELF-LIMITING - meaning it will fix itself
39
Subacromial Impingement Syndrome:
| Description + structures (5)
Signs & symptoms resulting in increased pressure on the structurs running under a narrowed sub-acromial space
Structures:
1. Subacromial (subdeltoid) bursa
2. Supraspinatus tendon
3. Long head of biceps tnedon
4. Coracoacrominal ligament
5. Joint capsule
40
Subacromial Impingement Syndrome:
Etiology
| (3)
**Primary (Structural) Impingement**
- Impingement as a result of congenital abnormalities or degenerative changes ot the acromion process, coracoid process, greater tuberosity, RCm or anterior tissues d/t stress overload causing impingement
Ie. hooked acromion, greater tuberosity
**Secondary (Functional) Impingement**
- Impingement as a result of abnormal force coupling action leading to mm imbalances & abnormal mvmt patterns
- Muscle imbalances & altered mvmt pattersn may be in the scapula or GHJ
- Secondary impingement may result after instability (loose anterior capsule)
**MM Imbalance & Posture**
Tight pec minor > ANTERIOR tilt of scapula > narrowing of subacrominal space, winging or weak lower traps, or kyphotic posture
**Calcific Tendonitis**
- Calcific deposit w/in a tendon (typically supraspinatus)
- Deposits produce bulge in tendon which increases the likelihood for impingement
- Typically found in supraspinatus tendon
41
Subacromial Impingement Syndrome:
S/S
| (8)
1. Glenohumeral painful arc (**60-120**) & end-range (posterior translation of clavicle) - HALLMARK
2. Pain
Worse w/ overhead activities (elevation) & lying on affected side
Location: anterior & lateral shoulder
**Pain does not radiate below the elbow**
Typically, no pain at rest
3. Tenderness on palpation of structures passing under subacromial arch (ie SSp tendon, LHB, subacromial bursa)
4. Reversed scapula-humeral rhythm
5. Decrease HBB & HBH ROM. Other mvmt may also be affected
6. Pain & weakness on resisted **abduction** and **ER**. Other mvmts may also be affected
*INC pain when resistance is performed w/in painful arc (60-120)*
7. May present w/ **antero-superior placed humeral head at rest**
*Posterior capsule tightness > IR stretching - may not be a good idea if sensitive b/c you are closing that space > pain*
8. May present with decrease postero-inferior glide
42
Special Test:
Hawkins Kennedy Impingement Test
Neer's Impingement
Scapular Assist Test
Hawkins Kennedy Impingement Test
- IR arm in front of pt > placing the greater tubercle into the narrow aspect of the subacromial arch where it compresses the other structures
(+) = pain
Neer's Impingement Test:
- PT places arm into IR (0 degree elbow ext) & passively flexes arm in scapular plane
- Bring the greater tubercle towards the narrow aspect of the subacromial arch SO compression happens earlier & more
(+) = pain
Scapular Assist
- ABD & PT helps facilitate the mvmt
(+) = decrease of pain
43
Muscle/ Tendon Pathology
| (4)
1. Tendintis: inflammation of tendon
2. Tendinosis: degenerative changes w/in a tendon w/out inflammation
Thought to be as a result of overuse & repetitive stress on the tendon causing degenerative microdamage
Typically takes longer to heal than tendinitis
3. Tenosynovitis: inflammation of the synovium (fluid filled sheath surrounding the tendon)
4. Tendon Rupture: tearing of a tendon
Occurs when the forces placed on the tendon are greater than the tensile strength & capacity of the tendon
May be partial or complete
44
Shoulder Tendinopathy
1. Biceps Tendinopathy
2. Supraspinatus Tendinopathy
3. Infraspinatus Tendinopathy
4. Teres minor Tendinopathy
5. Subscapularis Tendinopathy
45
Shoulder Tendinopathy: S/S
- Pain with mm contractions
MMT, AROM or AROM w/ restriction
- Tenderness upon palpation at tendon & insertion point
46
Speed's Test
Yergason's test
Biceps (LHB)
Yergason's - not specific for tendinitis - rather assess the ligament holding the LHB tendon
47
Drop Arm Test
"Empty" Can Test
Supraspinatus
Drop Arm Test (TEAR): lifting pt arm passively & tell them to hold this position & let go && they can NOT hold the position
"Empty can" Test - pathology
48
Belly Press Test
Lift-off sign
Internal Rotation Lag Sign
Subscapularis
49
Infraspinatus Test
Lateral Rotation Lag sign
Infraspinatus
50
Hornblower's Sign
Teres Minor
51
Scapular Dyskinesia
| Description
An alteration in the normal position or movement of the scapula
52
Scapular Winging
| (3)
Static Winging:
- Winging at rest
- Typically a result of structural deformity of the scapula, clavicle, ribs or psine
Dynamic Winging:
- Winging with movement
- May be due to:
Lesions of **long thoracic nerve** (serratus anterior) Spinal accessary nerve (trapezius)
C3-4 (trapezius)
C5 (rhomboids)
C7 (serratus anterior, rhomboids
Serrratus anterior weakness
Rhomboid weajness
Multidirectional instability
53
Wall or Floor Push Up Test
Scapular Load Test
Punch Out Test
Scapular Dyskinesia - Scapular Winging
Wall or Floor Push Up Test (wall = greater load)
Scapular Load Test - wt or manual resisting @ 45 of ABD ** Looking at scapula when doing the test.
Punch Out Test - making a fist w/ straight elbow & resisting protraction
54
55
Shoulder Separation
| Description & Etiology
Trauma to the ligaments holding the acromion & clavicle together causing separation between the two joint surfaces (subluxation or dislocation)
Etiology:
- Downward force on the acromion
- Directly falling on or hitting the acromion
- Falling on outstretched hand or falling on elbow
56
Shoulder Separation: S/S
| 3
Step Deformity
- Distal end of clavicle sticking up
- Grade 3 sprain: Both **acromioclavicular** & **coracoclavicular** ligaments have been torn
- Deltoid & trapezius mm may be torn from distal end of clavicle
Tenderness & swelling over AC joint
Pain w/ shoulder horizontal ADDuction, elevation, and HBB
- Horizontal = compressing the joint together
- Elevation = Flex or Abd > clavicle posterior rotates = any mvmt of clavicle = pain
- HBB = Extension + clavicle anterior rolls & any mvmt of clavicle = pain
57
Shoulder Separation: Radiology
| 1
Stress-view x-ray
- Patient hold weight onto each arm - **longitudinal TRACTION** to see if INC spacing
- Places an interior pressure on ACJ
57
58
Shoulder Separation: Rockwood Classification
Type I: "Sprain"
- Capsule is intact
- No seperation or excessive spacing is seen
Type II: "Subluxation"
- Increased ACJ spacing
Type III: "Dislocaton"
- Increased ACJ & costcoclavicular space - completely dislocated
- Joint surfaces not in contact with each other
58
59
Glenohumeral Joint Instability:
Classification
| 4
1. Direction: anterior, posterior, inferior, multidirectional
2. Degree: subluxation, dislocation (out of socket)
3. Etiology: traumatic, atraumatic - multi-directional instability
4. Timing: acute, recurrent
60
Shoulder Dislocation
| (3)
- Separation of the humerus from the scapula
- **Most commonly dislocatde joint in the body** - very mobile - many degrees of freedom
- **Anterior** dislocation is most common
*Stroke = inferior dislocation*
61
Glenohumeral Joint Instability:
Epidemiology
| 2
M>F
Typically seen in patients < 30 yo - younger ppl d/t the activities they do
62
Glenohumeral Joint Instability:
Etiology
| 2 Types (3+1)
Traumatic
- Direct trauma to humeral head
- Indirect trauma (force ROM) - keylock position in BJJ
- Most commonly while in ABDUCTION & ER = dislocate anteriorly
1. Stability in this position provided by subscapularis, GH ligaments (especially anterior band of the inferior ligament), & long head of biceps
2. **Anterior dislocation** may damage the subscapularis, long head of biceps, GH ligaments, anterior capsule, and anterior glenoid labrum
*Cut or shorten the SUBSCAO - restrictions into ER or resistance ER ~ 30 or contraction of subscap*
Atraumatic:
- General laxity in shoulder causes it to become unstable (HYPER mobile)
63
Glenohumeral Joint Instability:
S/S
| 8
1. Feeling of slippage pain
2. Feeling of insecurity w/ specific activities
3. **Possible pain or apprehension when appraching extreme ROMS**
4. DEC ROM during acute phase d/t apprehension
5. INC ROM during chronic phase d/t instability - hypermobility into the range d/t stretching of the structures
6. May appear normal on clinical examination, may become more apparent after **repeated activity** wehn fatigue sets in
7. Possible atrophy on affected side d/t disuse (chronic)
8. **Sulcus sign** may be present
*INFERIOR & LATERAL b/t glenohumeral head & acromion - instability (GHJ) or loss of mm control (stroke) or nerve palsy*
64
Glenohumeral Joint Instability:
Potential Complications
| 5
1. Axillary nerve injury: Must check for axillar nerve damage prior to reducing a subluxed or dislocated shoulder
*Check by testing the mm s the nerves innervate (MMT) = deltoid & teres minor*
2. Axillary artery: may be damaged w/ injuyr or reduction
3. Brachial plexus: less commonly damaged may occur to tohe branches of the plexus of which the **posterior cord is most common**
4. Bankart lesion: Most **anterior dislocations damage labrum**
5. Hill-Sach's lesion: posterolateral humeral head compression (indentation) fracture (Hill-Sach's lesion) may occur secondary to anterior shoulder dislocation d/t forceful impaction of the humeral head against the anteroinferior glenoid rim
*Indentation - dent - compression #
65
Shoulder Separation: Special Test
| 1
CrossBody (Horizontal) Adduction Test
66
Shoulder Separation: Radiology
| 1
Stress-view X-Ray:
- Patient hold weight onto each arm - **longitudinal traction**
- Places an inferior pressure on ACJ
67
Shoulder Separation: Special Test
| 1
CrossBody (Horizontal) Adduction Test
