# Chapter 15

What are the normal limits of SHOULDER AROM?
Flexion and Extension
Internal and External Rotation

FLEXION: 170-180
EXTENSION 50-60
Altogether: 220-240
ABDUCTION: 170-180
ADDUCTION: None initially, but same as abduction
INTERNAL ROT: 80-90
EXTERNAL ROT: 90-100
(This is done while elbow and shoulder = 90/90 degree)
HORIZONTAL ABD: 45 degrees
HORIZONTAL

What are the normal limits of ELBOW AROM?
Flexion and Extension

FLEXION: 145-155
EXTENSION: 0 (But could be 10-15 in females with hyperextension)

What are the normal limits of HAND/WRIST AROM?
Wrist PRONATION and SUPINATION
FINGER JOINT
FLEXION EXTENSION (MCP)
FLEXION EXTENSION (IP, Interphalangeal)

PRONATION and SUPINATION: Both 80-90. Total rom is 170-180
FLEXION: 85-105
EXTENSION: 20-30
Overall 105-135
Occurs in SAGITTAL PLANE
ABDUCTION: 25
Occurs in FRONTAL PLANE
IP FLEXION and EXTENSION:
PIP: 110-120
DIP: 80-90

What are the joints of the SHOULDER

Glenohumeral (GH) joint
Acromioclavicular (AC) joint
Sternoclavicular (SC) joint
Scapulothoracic articulation

What is scapulothoracic rhythm, and why is it important?
What is the "general ratio"?
Let's say we want to achieve 180 degrees of elevation. How will the joints work together?

In order to get MAXIMAL ARC RANGE OF MOTION,
the GH JOINT and SCAPULOTHORACIC ARTICULATION must work together in harmony.
RATIO: 2 to 1, GH Joint to SCAPULOTHORACIC
120 degrees will come from GH JOINT, and 60 degrees will come from SCAPULA

What is the order of the BASEBALL THROWING PHASES?
What is significant about each phase?

WINDUP -> EARLY COCKING -> LATE COCKING -> ACCELERATION -> DECELERATION -> FOLLOW THROUGH
WIND UP = KNEE UP
EARLY COCKING + LATE COCKING = FOOT CONTACT
ACCELERATION = MAX EXTERNAL ROTATION
DECELERATION = RELEASE
FOLLOW THROUGH = MAX INTERNAL ROTATION

What muscles cause these scapular/shoulder movements?
ELEVATION
DEPRESSION
PROTRACTION
RETRACTION
DOWNWARD ROT
UPWARD ROT

ELEVATION: Upper TRAP and LEVATOR SCAPULAE
DEPRESSION: LOWER TRAP is the prime mover. MIDDLE TRAP works as well
PROTRACTION: SERRATUS ANTERIOR (Plus Pect Major + Minor)
RETRACTION: RHOMBOIDS + MIDDLE TRAP
DOWNWARD ROT: RHOMBOIDS
UPWARD ROT: SERRATUS ANTER

With SC JOINT SPRAINS, what is the:
MOI
SIGNS AND SYMPTOMS
What happens if there is a POSTERIOR SC JOINT SPRAIN?

MOI: LONGITUDINAL force on CLAVICLE
Also: FOOSH, HIT on LATERAL SHOULDER,
Signs and Symptoms:
PAIN with PROTRACTION, RETRACTION, and JOINT PLAY
POSTERIOR = MEDICAL EMERGENCY!
Why? Because it threatens the SUBCLAVIAN ARTERY/VEIN, ESOPHAGUS, and TRACHEA

With AC JOINT SPRAINS, what is it generally equated to? Next, what is the MOI?
What are AC joint CLASSIFICATIONS based on?

SEPERATED SHOULDER
MOI: FOOSH, Blow to superior ACROMION PROCESS
Based on:
-Structures involved
-Degree of Instability
-Direction of displaced clavicle

What are the types of AC JOINT SPRAINS?

TYPE I: Partial tear/damage to AC Ligament
TYPE II: AC Ligament RUPTURE
TYPE III: AC Ligament + CC (Coracoclavicular) Ligament
TYPE IV: Previous stuff + TEARING OF DELT + TRAP FASCIA (Clavicle gets displaced POSTERIORLY)
TYPE V: Same as IV, but clavicle g

What are the types of GLENOHUMERAL INSTABILITY pathologies?

ANTERIOR
POSTERIOR
INFERIOR
MULTIDIRECTIONAL

What special tests are used for GH instability (ANTERIOR)?

-APPREHENSION (Off table, Arm 90/90, Passive EXT ROT, positive if pain or guards)
-RELOCATION (Same as apprehension, but apply POSTERIOR FORCE to humeral head while ext rotate
-ANTERIOR RELEASE (AKA SURPRISE). Continuous with relocation. Just release the

What special tests are used for GH instability (POSTERIOR)?

POSTERIOR APPREHENSION (Shoulder flexed to 90 + Elbow flexed to 90, Apply longitudinal force to humeral head, mmaking it move POSTERIORLY. Check for guarding and apprehension)
JERK TEST (Arm is Flexed while Shoulder is INT ROTATED to 90. Examiner passivel

What special tests are used for GH instability (INFERIOR)?

SULCUS SIGN (Pull down on arm aka downward traction while scapula is stabilized. Positive if INDENTATION appears below Acromion process.

What special tests are used for GH instability (MULTIDIRECTIONS)?

The previous ones for ANTERIOR and POSTERIOR
Apprehension, Relocation, Posterior Apprehension, and Testing for posterior instability in plane of scapula.

What are the ROTATOR CUFF PATHOLOGIES?

IMPINGEMENT
RC TENDINOPATHY
SUBACROMIAL BURSITIS

What are the types of RC IMPINGEMENT?

PRIMARY (Irregular acromion, Bone spur)
SECONDARY (Loss of humeral head depression, has GH instability, poor posture, scapular dyskinesis)
INTERNAL (Glenohumeral internal rotation deficit aka GIRD, Comes from THROWING or OVERHEAD MOVEMENT REPETITIVELY OVE

What special tests are used for RC IMPINGEMENT?

NEER (Passive SHOULDER FLEXION while arm is close to ear. Near to the ear. Positive if painful)
HAWKINS-KENNEDY (Arm flexed and shoulder raised to 90 degrees. Passively INTERNAL ROTATE HUMERUS checking for pain)
DROP ARM

How does BICEPS TENDINOPATHY OCCUR?

Rotator cuff dysfunction and IMPINGEMENT, because of where the biceps insert.

What special tests are used for BICEPS TENDINOPATHY?

YERGASON'S (Elbow flexed to 90. Move GH joint into EXT ROTATION while RESISTING SUPINATION. Positive if painful or snapping.)
SPEED'S (Elbow is extended. Checks RESISTIVE ELBOW and GH JOINT FLEXION, allowing patient to move through ROM. Pain at biceps lon

What are SLAP LESIONS?

Superior Labrum Anterior to Posterior lesions
Tears of the SUPERIOR LABRUM that extend to ANTERIORLY and POSTERIORLY to BICEPS INSERTION.

What are the CLASSIFICATIONS of SLAP LESIONS?

TYPE I (Degeneration/Fraying of Labrum)
TYPE II (Now with Labrum avulsed and long head of BICEPS TENDON TORN)
TYPE III (BUCKET HANDLE TEAR with NO INVOLVEMENT OF LHBT or long head biceps tendon)
TYPE IV( BUCKET HANDLE TEAR but with LHBT TEAR)

What are the special tests for SLAP LESIONS?

1. Active compresion aka O'BRIEN (Shoulder flexed to 90 and horizontally adducted 15 degrees. Humerus = INT ROTATED, Elbow EXTENDED, Forearm PRONATED.
ISOMETRIC RESISTANCE AGAINST DOWNWARD FORCE. Checks for painor clicking.)
2. ANTERIOR SLIDE (Hands on hi

What are the ways to FUNCTIONALLY TEST the upper extremity?

Try to perform a PUSH-UP
APLEY'S SCRATCH TEST (Touch opposite shoulder, Go over behind the back and touch opposite scapula, Go below and behind the back and touch opposite scapula)

What is the appropriate management of acute shoulder injuries SC, AC, and GH JOINT INJURIES (fractures or dislocations)

SC: NEUROLOGICAL/VASCULAR CHECK > IMMOBILIZE > TRANSPORT to medical facility
AC: IMMOBILIZE (Do it in a position that will bring the clavicle and acromion process closer together) > PROTECT JOINT (Use extra padding)
GH: Check DISTAL PULSE/FINGERTIP CIRCUL

If GH REDUCTION does happen, what should be done next?

Check DISTAL PULSE and AROM (No EXT ROTATION and ABDUCTION > STABILIZE SHOULDER > REFER ATHLETE

What's the GENERAL PROCESS for MANAGING ACUTE SHOULDER INJURIES?

IMMOBILIZE arm on the affected side > TRANSPORT
If GH DISLOCATION, a RADIOGRAPH may be necessary to rule out other fractures

What's the appropriate management of acute shoulder injuries (CLAVICULAR and HUMERAL FRACTURES)

CLAVICLE: IMMOBILIZE WITH SLING > TRANSPORT
HUMERAL: SPLINT IN POSITION FOUND > Leave WRIST AND FINGERS EXPOSED to keep circulation > TRANSPORT