Subacromial Impingement Presentation (ORCLAP)
-Age >40
-Repetitive overhead activities
-Overuse of arm in unaccustomed positions
-Lateral shoulder pain
-Painful arc
-Compensatory shoulder shrug
Subacromial Impingement Key Impairments
WEAK traps, serratus, RC
SHORT pec minor/major, lats
Dominant rhomboid, pec minor/major, lats
DECREASED inferior/posterior GH glide
DECREASED scapulothoracic mobility
Subacromial Impingement Key Tests & Measures
Hawkins-Kennedy test **
(+) = pain in lateral shoulder w/ IR
Infraspinatus test
(+) = pain/weakness when resistance is applied
Painful arc
(+) = pain from 60-120 degrees
Rotator Cuff Tear Presentation (MICCLAN)
-Age >40
-Macrotrauma w/ functional disability
-Idiopathic onset of functional disability
-Pain in lateral aspect of arm
-Pain is constant
-Night pain is frequently present
-Compensatory shoulder shrug
Rotator Cuff Tear Key Impairments
WEAK traps, serratus, RC
SHORT pec minor/major, lats
Dominant rhomboid, pec minor/major, lats
DECREASED inferior/posterior GH glide
DECREASED scapulothoracic mobility
Rotator Cuff Tear Key Tests & Measures
Drop arm test **
(+) = patient unable to do due to pain, or arm drops suddenly; more specific than sensitive
Infraspinatus test
(+) = pain/weakness when resistance is applied
Painful arc test
(+) = pain from 60-120 degrees
Shoulder Instability Presentation (PITDARD)
-Instability: 66-100% <20 years old
-Primary dislocations: most common in 2nd and 6th decades; mostly anterior
-TUBS or AMBRI
-Diffuse pain over anterior/posterior shoulder
-Apprehension w/ abduction/ER
-Repetitive overhead activities
-Delayed onset of pa
Shoulder Instability Key Impairments
WEAK traps, serratus, RC
SHORT pec minor/major, lats
Dominant rhomboid, pec minor/major, lats
INCREASED GH anterior glide
DECREASED GH posterior glide (if anterior instability)
Poor NM control of scapulothoracic mobility
Shoulder Instability Key Tests & Measures
Apprehension-relocation test (anterior)
Load & shift test (multi-directional)
Sulcus test (inferior)
Labral Injury Presentation (LODMM)
-Pain located "deep" or "in" the shoulder
-Locking, popping, clicking
-Increased pain w/ overhead activities
-May mimic RC/AC joint involvement
-Macrotrauma or microtrauma
Labral Injury Key Impairments
WEAK traps, serratus, RC, biceps
SHORT pec minor/major/lats
Dominant rhomboid, pec minor/major, lats
DECREASED IR/posterior glide
INCREASED GH anterior glide
Labral Injury Key Tests & Measures
Active Compression Test (O'Brien Test)
(+) = reproduction of popping/clicking/pain when arm is pronated and decreased complaints when arm is supinated (more specific than sensitive)
Shoulder Instability Tests
Drop Arm Tests (rule out RC)
AC Joint Injury (A MF/D CE P3)
-Males > females
-Age 20-30
-FOOSH or direct blow to top of shoulder
-Pain, swelling, AC joint tenderness
-Clavicular elevation
-Pain w/ flexion, reaching across body
-Pain laying on that side
AC Joint Injury Key Impairments
AC joint mobility
SC joint mobility
GH joint mobility
Scapulothoracic joint (NM control)
SHORT pec minor, lats
AC Joint Injury Key Tests & Measures
Active Compression Test (O'Brien Test)
Cross Body Adduction Stress Test
AC Resisted Extension Test
Thoracic Outlet Syndrome Presentation
-Female, late teens to 4th decade
-Sedentary job w/ static use of UEs, repetitive use of the hands
-Deconditioned
-Forward head, protracted shoulders
-Depressed/downwardly rotated scapulae
-Vague, ill defined symptoms
-Upper quadrant pain, paresthesia, nu
Thoracic Outlet Syndrome Key Impairments
-Limited cervical ROM/upper thoracic & cervicothoracic restrictions
-Posture
-Elevated 1st rib
-Positive ANTT (patient describes)
-Anterior capsule laxity of GH joint
-Presence of cervical rib/abnormal 1st rib/large C7 TP
-Dominance of scalenes
-SHORT pec
Thoracic Outlet Syndrome Key Tests & Measures
Adson's Test
Costoclavicular Assessment
Pec Minor Test
Anterior Capsule Test
Roos Test
Shoulder elevation muscle action needs (strength & NM control)
-upper, middle, & lower trapezius
-serratus anterior
-supraspinatus
-deltoid
Shoulder elevation muscle length needs
-pectoralis minor
-latissimus dorsi
-pectoralis major
Functions of the labrum
-deepens glenoid cavity by 50%, thereby increasing stability without sacrificing mobility
-acts like a seal
-attachment of GH ligaments
Coracoclavicular ligaments
Trapezoid
- runs lateral/superior; limits decrease of clavicular-scapular-horizontal angle (closing) (primarily prevents lateral displacement and secondarily posterior translation)
Conoid
- fan shaped, lies in frontal plane; limits increase of the clavicu
GH joint positions
Resting
- 55 degrees abduction, 30 degrees horizontal adduction
Close packed
- full abduction & ER
Capsular pattern
- ER, abduction, IR
AC & SC joint positions
Resting
- resting by side in normal physiological position
Close packed
- AC joint is abduction to 90 degrees; SC joint is full elevation
Capsular pattern
- pain at end range
Stages of impingement syndrome
Stage I
- edema & hemorrhage; <25, reversible, conservative treatment
Stage II
- fibrosis & tendinopathy; 25-40, recurrent pain, consider subacromial decompression
Stage III
- bone spurs & tendon rupture, >40, progressive disability, surgical repair
Primary vs. secondary impingement
Primary
- mechanical GH impingement; altered/reduced subacromial space ("block"); structures involved include subacromial arch/space and subacromial bursa
Secondary
- movement impairment syndromes causing faulty biomechanics leading to tissue breakdown
Shoulder stability components
-bony congruence - enhanced by labrum
-negative pressure - at side & at rest
-muscles & tendons - static & dynamic
-ligaments & capsule
Glenohumeral ligaments
Superior
- limits anterior/inferior translation of abducted humerus
Middle
- limits anterior translation in lower/middle range of abduction
Inferior
- primary constraint against anterior/posterior/inferior translation when humeral abduction >45 degrees
GH ligaments in adduction
-supraspinatus in conjunction w/ incline of glenoid keeps joint congruent at rest
-stroke/full thickness tear --> humeral head migrates inferiorly (sulcus sign)
GH ligaments in abduction
-middle GH ligaments start to play a bigger role
-inferior GH ligament plays significant role in limiting anterior translation at 90 degrees - this is the position most dislocations occur in
TUBS vs. AMBRI (instability spectrum)
TUBS
(torn loose)
-traumatic
-unidirectional
-Bankart lesion
-surgery
AMBRI
(born loose)
-atraumatic
-multidirectional
-bilateral
-rehab effective
-inferior capsular shift
Associated injuries w/ GH dislocation
Hill Sachs lesion
- posterolateral aspect of humeral head sustains compression fracture as it strikes the glenoid rim during dislocation
Bankart lesion
- bony avulsion to the anteroinferior labrum from the rim (labrum separated from the glenoid)
AC joint stability - static
-AC ligaments & joint capsule
-coracoclavicular ligaments
AC joint stability - dynamic
-delto-trapezial fascia
-attachments along lateral clavicle, acromion, and spine of scapula
-serves to resist migration of clavicle and support AC joint
AC joint injury classifications
Type I - AC ligament sprained; joint is intact (0%)
Type II - AC ligament torn; CC ligaments intact (0-25%; clavicle displaced upward)
Type III - AC & CC ligaments torn; delto-trapezial fascia intact (25-100%, clavicle displaced upward)
Type IV - complete
Surgical intervention categories for AC joint injury
-direct AC joint fixation
-nonanatomical CC fixation with screws or sutures
-anatomical CC ligament reconstruction
GH joint orientation
Glenoid fossa - lateral, anterior, superior
Humeral head - medial, posterior, superior
AC joint orientation
Acromial surface - superior, anterior, medial
Clavicular surface - inferior, posterior, lateral
Joint capsule
-attached to circumference of labrum & neck of humerus
-inferior capsular fold allows abduction
-reinforced by RC, pec major, & teres major
-glenohumeral and coracohumeral ligaments blend into joint capsule
Frozen shoulder presentation
-painful/restrictive active & passive ROM
-affects 2-5% of general population and 10-38% of those with diabetes or thyroid disease
-primarily affects those 40-65 y/o
-females > males
-primary: idiopathic
-secondary: intrinsic vs. extrinsic vs. systemic
Results of frozen shoulder
-hardening of redundant axillary folds
-synovial capsule thickening
-contracture of GH joint
-dense adhesions
Frozen shoulder differential diagnosis
-RC tears
-tendinopathy
-osteoarthritis
-labral tear
-subacromial bursitis
Adhesive Capsulitis Stage 1
-symptom duration: 0-3 months
-pain w/ AROM/PROM
-limited flexion, abduction, ER, IR
Adhesive Capsulitis Stage 2
-"freezing" (seen most in PT)
-symptom duration: 3-9 months
-chronic pain w/ AROM/PROM
-significant limitations in flexion, abduction, ER, IR
Adhesive Capsulitis Stage 3
-"frozen"
-symptom duration: 9-15 months
-minimal pain w/ AROM/PROM
-significant limitation in ROM w/ rigid end feel
Adhesive Capsulitis Stage 4
-"thawing"
-symptom duration: 15-24 months
-minimal pain
-progressive impairment in ROM
Adhesive Capsulitis High Irritability
-high pain (>/= 7/10)
-consistent night or resting pain
-high disability on DASH, ASES, PSS
-pain PRIOR TO end ROM
-AROM less than PROM, secondary to pain
-1-5 sec ROM/stretch, pain-free, passive AAROM
-low-grade mobilization
-intra-articular steroid inje
Adhesive Capsulitis Moderate Irritability
-moderate pain (4-6/10)
-intermittent night or resting pain
-moderate disability on DASH, ASES, PSS
-pain AT end ROM
-AROM similar to PROM
-5-15 sec ROM/stretch, passive, AAROM to AROM
-low- to high-grade mobilization
-basic functional activities
Adhesive Capsulitis Low Irritability
-low pain (</= 3/10)
-no resting or night pain
-low disability on DASH, ASES, PSS
-minimal pain at end ROM with overpressure
-AROM same as PROM
-end range/overpressure ROM/stretch, increased-duration, cyclic loading
-high-grade mobilization/sustained hold
Layers of the supraspinatus/infraspinatus
1 (most superficial) - fibers of coracohumeral ligament
2 & 3 - thick tendinous structure
4 - loose connective tissue
5 - joint capsule
Rotator cable
-strip of fibrous tissue between 4th & 5th layers
-extends from coracohumeral ligament --> supraspinatus tendon (articular side) --> infrapinatus tendon (inferior border)
-crescent tissues lies lateral to cable
-complex likened to suspension bridge - infl
Classification of partial RC tears
-Grade 1: <1/4 thickness (~3 mm)
-Grade 2: <1/2 thickness (3-6 mm)
-Grade 3: >1/2 thickness (6+ mm)
RC tear locations
-superior - supraspinatus
-superoposterior - supraspinatus & infraspinatus (most common)
-superoanterior - supraspinatus, rotator interval, subscapularis & +/- long head of biceps
RC tear Goutallier fatty degeneration staging
-Stage 0 - completely normal muscle, without any fatty streaks
-Stage 1: the muscle contains some fatty streaks
-Stage 2: muscle > fat
-Stage 3: fat = muscle
-Stage 4: fat > muscle
RC surgical repair rehab depends on
-surgical approach
-size & location of tear(s)
-quality of tissue and bone
-quality of fixation
-concomitant injuries & repairs
RC repair concomitant surgical procedures
-
SLAP/labral repair
- peel-back risk, no biceps work
-
biceps tenodesis
- no active elbow flexion/supination for 4 wks, no "bowling" position (combined shoulder & elbow extension w/ supination) for 3 months
-
subscapularis repair
- no active IR/GH extens
TSA pathology/general indications
-pain
-RTC failure
-osteonecrosis (AVN)
-degenerative joint disease (OA/RA)
-failed hemi-arthroplasty
-complicated proximal humeral fracture
general indications
-persistant shoulder pain
-loss of function
-presence of advanced pathology
-failed conservati
Indications for traditional TSA
-severe degenerative changes of humeral head
-revision after hemi-arthroplasty
-intact RTC ****
Indications for rTSA
-irreparable rotator cuff**
-complex fractures
-elderly w/ poor bone quality and/or RTC tissue quality
-GHJ arthritis
-tumor of proximal humerus
-failed TSA w/ "non-usable" RTC
rTSA biomechanics
-reversed orientation of GH joint
-glenoid fossa replaced w/ glenoid base plate & glenosphere
-humeral head replaced w/ shaft & concave cup
-center of rotation of GH joint = medial & inferior ** (increased lever arm distance/deltoid force; torque of abduc
Dislocation of TSA/rTSA
TSA - combined abduction/ER
rTSA - combined IR, adduction, & extension
MCID of UE Outcome Measures
SPADI - 8-10 pts
PSFS - 2 pts (3 for individual items)
QuickDASH - 8 pts
NPRS (VAS) - 1.8 pts (2 pts)
GRC - small: 1-3; moderate: 4-5; large: 6-7
Mechanisms of organ systems referral
-convergent innervation
-respiratory diaphragm pressure
-retroperitoneal or abdominal distention
Referral patterns
Cardiovascular/pulmonary --> shoulder, scapula, elbow, medial arm & wrist
GI/biliary/renal & urologic --> sternum, neck, shoulder, scapula, subscapular/interscapular regions
Oncologic Conditions: CAUTION
C: change in bowel or bladder habits
A: a sore throat that does not heal in 6 weeks
U: unusual bleeding or discharge
T: thickening or lump in the breast or elsewhere
I: indigestion or difficulty swallowing
O: obvious changes in a wart or mole
N: nagging c