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Shoulder Anatomy

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Shoulder Evaluation
Chapter 13, p. 424
Shoulder Anatomy: Scapula
• Borders
• inferior
• superior
• Fossa
• supraspinous
• infraspinous
• Processes
• coracoid
• acromion
• Motion (scaption)
Shoulder Anatomy: Humerus
• Humeral head
• Tuberosities:
– Greater (lateral)
– Lesser (medial)
– Bicipital Groove
• Glenohumeral Joint
– Instability/laxity
– Labrum
– Capsule
Shoulder Anatomy: Rotator Cuff
(P. 432)
• Supraspinatus
– assists deltoid in ABD
– ER
• Infraspinatus
– ER/Hor. Abd
– Decelerator (ECC)
• Teres Minor
– ER/Hor. Abd
– Decelerator (ECC)
• Subscapularis
– only pure IR muscle
• Force Couple:
– RC:Deltoid
– Stabilizing effect
– Fig. 13-15, p. 433
Shoulder Anatomy: Bursae
(p. 437)
• Purpose
• Subacromial bursa
– location
– subacromial/subdeltoid
Shoulder Evaluation: History
(p. 437-439)
• Location
• Mechanism of injury
– know the anatomy
– know the biomechanics
• Onset:
– acute?
– chronic?
– worsen or improve with•
activity?
– Duration of pain?
• PMH (biomechanics)
–
–
–
–
Overhead activity
Collision
Excessive ROM
Repetitive motion
Complaints
– “sliding out of place”
– aching or “dead”
– popping
Shoulder Evaluation:
Observation
(p. 439)
• Position of the head
– 2º neck injury?
– Muscle spasm?
• Level of the shoulders
– dominant=lower
– clavicles & scapulae
• Contour of clavicles
• Fig. 13-18, p. 439
Shoulder Evaluation:
Observation
(p. 439-442)
• Symmetry
–
–
–
–
muscle tone
atrophy (infraspinatus)
levels
GH joint position
• Vertebral alignment
Shoulder Evaluation: Palpation
(p. 442-444)
• Clavicle
– SC->AC
– angulations
– piano key sign
• Rotator cuff insertions
• Glenohumeral (GH)
joint
• Biceps Tendon
• Anatomy: p.442, 444
Shoulder Evaluation: Palpation
•
•
•
•
•
•
•
Deltoid
Spine of the scapula
Supraspinatus
Infraspinatus
Levator scapulae
Rhomboids
Trapezius
Shoulder ROM
• Apley’s Scratch Test
– Apley’s Scratch test: p.447,
Box 13-3
– opposite shoulder from
front
– opposite shoulder from
behind
– opposite shoulder over head
– evaluates multiple ROM’s
Shoulder ROM
• Drop arm test
– P. 449, Box 13-4
– (+)= Rotator cuff tear
– Uncontrolled drop in
AROM ABD
Shoulder ROM
(p. 437)
• Scapulothoracic Rhythm
– GH abduction
– 2:1 ratio of GH to
scapular movement
– example: 180º =
• 120º GH
• 60º scapular rotation
– bilateral/symmetrical
Functional Testing
(p.444-458)
• Force Production
– IR/ER:
• 3:2 CON
• 3:4 ECC
• ROM
–
–
–
–
Flex/Ext
ABD/ADD
ER/IR
Hor. ABD/ADD
Shoulder Pathologies:
•
•
•
•
•
•
•
Acromioclavicular injuries
Glenohumeral Instability
Rotator Cuff Strains
Rotator Cuff Impingement
Rotator Cuff Tendinitis
Biceps Tendon Injuries
Thoracic Outlet Syndrome
Acromioclavicular (AC) Joint
Injuries
(p. 460-461, Table 13-8)
• History
– Acute trauma or overuse
– FOOSH mechanism
– “separated shoulder”
•Palpation
–Tender AC joint
–AC laxity
– (piano key sign)
• Observation
– Step deformity possible
– Clavicles not level
• Examination
– Traction Test
• p. 462, Box 13-10
– Compression Test
• p.463, Box 13-11
Clavicle Fractures
Glenohumeral Instability
(p. 463)
• History
– Unidirectional or
multidirectional
– Anterior/inferior most
common
– Excessive ROM mechanism
or FOOSH
– Easily becomes chronic
– “Dead Arm Syndrome”
– Reports a pop
– Subluxation->dislocation
• Observation
– Obvious deformity with
dislocation
– Guarded presentation
– Bankart lesions
– Hill-Sachs lesions
• Palpation
–
–
–
–
Obvious GH deformity
Tender at RC insertions
Assess instability direction
Check radial pulse and
sensation
Glenohumeral Dislocations
• Obvious deformity
• Check distal pulse
often
• Reduction strategies
• Humeral fx possible
• Splint and refer +/reduction
GH Joint Damage
• Bankart Tear--p. 463
• Torn anterior labrum following
chronic GH instability
• Labrum avulses from glenoid
fossa
Hill-Sachs Lesion—
p.466
•posterolateral humeral head
indentation fracture
• soft base of humeral head
impacts glenoid
• occurs in 35-40% of
anterior dislocations & up to
80 % of recurrent dislocat.
SLAP Lesions
• Superior Labrum
AnteroPosterior lesion
• Near LH Biceps tendon
• Pain worsens with ECC
biceps work (followthrough motions)
• Sx repair slow rehab
progression
• Classifications:
– 4 Classes
– P. 480: Table 13-13
Special Tests: SLAP Lesions
• O’Brien Test
– Active Compression
test
– 90-90position with
HAdd
– RROM Trials in IR and
ER
– (+) test= pain or
clicking at GH joint
(not AC)
– False (+) common
Special Tests: GH Joint
(p. 453)
• Anterior Apprehension
Test
– Identifies chronicity of
anterior instability
– Figure Box 13-5
– PROM ER of GH in
90-90 position
– Positive (+)= Extreme
guarding during test
indicates ant laxity or
labrum tear
Special Tests: GH Joint
(p. 465)
• Relocation Test
– Confirms instability in
GH joint
– Box 13-12
– Apprehension test with
posterior GH pressure
– Positive (+)= increased
ER or decreased pain
without extreme
guarding
Special Tests: GH Joint
(p. 456)
• Posterior Apprehension
Test
• Box 13-13
• PROM post. Force in 90
shoulder/elbow flex
• Positive (+)= Extreme
guarding during test
• Indicates post. Laxity or
labrum tear
Special Tests: GH Joint
(p. 469)
• Sulcus Sign
– Confirms instability in
GH joint
– Box 13-15
– Traction on humerus
– Positive (+)= increased
opening/laxity at GH
joint (AC joint remains
NML)
Rotator Cuff Strains
p. 474—Table 13-12
• History
–
–
–
–
excessive ECC motions
excessive ROM
Dislocation/subluxation
PMH of RC tendonitis
• Palpation
– tender at RC insertions
– possible posterior pain
– Crepitus possible
• Observation
– no significant swelling
– altered posture
– overhead motions painful
– painful arc
Special Tests: Rotator Cuff
p. 475
• Empty Can Test
–
–
–
–
–
Cintinela Test
Box 13-19
(+)= Rotator cuff strain
Test (B)
Multiple tests/trials
Special Tests: Rotator Cuff
p. 455
• Gerber Lift-Off Test
• Box 13-7
• Position: shoulder IR
behind back
• Lift hand away from
back
• Isolates subscapularis
Shoulder Impingement
(P. 470, p. 471--Table 13-11)
• History:
– usually chronic
– common with overhead
sports
• Palpation:
– possible crepitus
– tender RC insertions
– possible bicipital groove
pain
• Observation:
–
–
–
–
limited AROM
painful arc
altered mechanics
usually no obvious
inflammation
• Examination
– Neer’s test
– Hawkins test
Rotator Cuff Impingement:
Special Tests
• Neer’s test
– P. 472: Box 13-16
– PROM shoulder
flexion
– (+)= pain at endrange
– May indicate LHB
pathology
Rotator Cuff Impingement:
Special Tests
• Hawkin’s test
– P. 473—Box 13-17
– PROM shoulder IR
with flexion
– (+)= pain at endrange
– May indicate LHB
pathology
Rotator Cuff Tendinitis
(P. 471)
• History:
– slow onset
– PMH~impingement or
instability
• Palpation:
– subacromial/deltoid pain
– Posterior pain possible
– RC insertions painful
• Observation:
– decreased AROM
– guarded presentation
– possible post. Atrophy
• Examination:
– Drop arm test
– Empty can test
– Impingement tests
Biceps Tendon Pathology
(p. 4476)
• History:
• Observation:
– PMH~RC pathology
– Overuse or acute onset
– Forced ROM (ER or Ext)
with elbow ext.--ECC or
CON
• Palpation:
– Tender at bicipital groove
• Transverse ligament
– Subluxation of BT
– dec. MMT in biceps
– altered mechanics
– Inflammation
• Examination:
– Yergason test
– Speed’s test
– Impingement tests
Biceps Tendon Pathology: Special Tests
(p. 477
• Yergason Test:
– Attempt to sublux BT
– Resisted elbow
flexion/supination
– (+)=pop/snap with pain
• transverse lig. Sprain
• biceps tendonitis
• biceps impingement
– Box 13-20
Biceps Tendon Pathology
Special Tests:
(p. 478
• Speed’s Test:
– Confirms BT inflammation
– Resisted flexion with GH in
anatomical position
– (+)= pain at BT with
RROM
• no pop/snap felt
• Box 13-21
Thoracic Outlet Syndrome
(P. 480)
• History:
– Usu. congenital problem
– C7 “extra rib”
– Neurovascular complaints
as structures are
compressed
• Palpation:
– Decreased pulse with
Adson’s test
– Altered
sensation/temperature
– Joint edema possible
• Observation:
– x-rays indicates “extra” rib
– Poor posture (rounded
shoulders, forward head)
• Examination
– Adson’s test
– Allen test
Thoracic Outlet Syndrome
Special tests:
p.482—Box 13-24
• Adson’s test:
– Attempt to reproduce
pressure on neurovasc.
bundle
– ER/ext of shoulder with ext
of neck
– Monitor radial pulse during
test
– (+)= diminished pulse
during test
• false (+) frequent
• test (B)
Thoracic Outlet Syndrome Special tests:
p. 483—Box 13-25
• Allen test:
– Attempt to reproduce
pressure on neurovasc.
bundle
– ABD/ Hor. ABD of
shoulder with rot of neck
– Monitor radial pulse during
test
– (+)= diminished pulse
during test
• false (+) frequent
• test (B)
Pitching Motion
(P. 438)
• 5 phases
• 90 º GH ABD
• Trunk and legs for
power
• CON-ECC forces for
power and protection
• Pitcher vs. Catcher?
Shoulder Motion
• Mobility > Stability
• Overuseпѓ Altered
Biomechanicsпѓ injury
• Good biomechanics
prevent injury
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