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Ortho Shoulder 2009
Orthopedic Management of shoulder
| Question | Answer |
|---|---|
| Watershed effect is | area of relative transient hypovascularity, pain w/abduction 60-120 deg forward flex, forced IR w/90 deg abd |
| causes of impingment | muscular imbalance, faulty biomechanics, trauma (MVA), immobilization, poor posture (most often) |
| S.I.C.K. scapula | Scapular malpostion, Inferior medial border prominence, Coracoid pain & malposition, Dyskinesis of scapular movement |
| symptoms of SICK | impingment symptoms assoc w/decreased posterior tipping & dec upward rotation during humeral elevation |
| clinical manifistation - painful arc 60-120 deg of flex or abduction, pain w/resistance (to inflam tendons), pain w/stretch (of inflam tendons), tenderness to palpation at distal insertions, limited IR (MEASURE W/GON) | SICK scapula |
| pain &/or weakness w/resistance to shoulder: flexed 90 deg, abd 45 deg horz. abd, & IR indicates? | supraspinatus tendon is inflamed & impinged |
| Empty Can test | tests supraspinatus stg in impingment position, may be + w/subacromial bursitis & inc tears |
| Full Can | test integ of supraspinatus tendon, pain &/or weakness w/resistance to shoulder: flexed 90 deg, 45 deg horz abd, ER, indicates inflamed or torn |
| neer impingment | to pinch LHB or supraspinatus tendon betw head of humerous & acromion. pain w/passive movement of shoulder above 90 deg flex w/slight over pressure |
| hawkins | impingment, passive shoulder flex to 90 deg & shoulder IR, + if produces pain |
| painful arc | to determine presence of impingment - presents w/pain while actively abd arm betw 60-120, if painful at end range, the AC jt may be involved as well |
| drop arm test | clinician holds patient's arm out, if pt cannot actively descend & it drops, sign of probable tear of RC |
| Impingment, avoid what movements? | abd below 45 deg (watershed effect), flex above 90 deg (Hawkins) |
| Impingment, what to strengthen? | serratus anterior, trapezius, levator scapulae, rhomboid, shoulder blade squeezes |
| Impingment, what to stretch? | external rotators, possibly internal rotators (w/good posture) |
| Impingment, when to start exercises? | late max, so long as no further impingment inc symptoms |
| position for arm/bicep exercise | seated, arm on plinth, put it at 45 deg, towel maybe under arm pit |
| to gain ROM in shoulder ER, you stretch____ | internal rotators |
| MAX phase impingement | PRICE, avoid motions above 90 deg, NSAIDS, Ionto/phono, estim, cross-friction msg, ice, PROM, tx w/shoulder support @ 45 deg abd (watershed), ALL MOTION (FLEX &/OR ABD) ABOVE 90 DEG S/B IN ER UNLESS OTHERWISE NOTED!!!!!!!, scapular stg if painfree |
| MOD phase impingement | scap ex (rowing-rhomboids, scap plane eleva-scaption w/ER, seated press ups -upper & lower trap, pushups w/scap prot, at end, pushup plus -up & down w/o bending elbows -SA, RH, AROM lim to 90 deb abd, strtch to mntain ROM, restore IR 90 deg, start w/isom |
| MOD phase impingement strength trng | start w/isom, (work towards isot, isok), Isotonics w/theraband, free wts, scaption: AVOID IR & SCAPTION ABOVE 45 DEG, isokinetics (UBE, IR/ER high speeds) |
| scaption plane is often preferable to the frontal or sagital plane because? | less muscle effort is required to raise the arm in the scaption plane |
| MOD phase impingement, watch ..... | POSTURE (very important), biomechanics, functional activities: activity modifictions |
| MIN phase impingement | functional, return to activities, above 90 deg, concentrate on RC, supraspinatus, infraspinatus, teres mior, supscapularis ( concentric and eccentric), concentrate on scapular retractors & stablizers (rhomboids, Serratus anterior, trap, levator scap w/wts |
| MIN phase impingement | stretching bilateral, strengthening in available range ASAP, work towards overhead strength as tolerated, wt machines pain-free, functional |
| two common bursitis to be painful | subdeltoid, subacromial |
| characteristics of bursitis | often 2 deg to RC lesion/impingment, constant dull, sometimes throbbing pain, all movements painful |
| site pain for bursitis | lateral brachial area (deltoid area), might be referred distally, bursa has no neurons connecting so it is the structure that does & is affected |
| Bursitis restrictions | AROM in all planes, especially in overhead motion, PROM restricted in non-capsular pattern, empty end feel |
| Bursitis - how to strengthen? | resistance |
| Patient education for bursitis | don't overwork w/o breaks, do not work when in pain or inflammed |
| Bursitis rehab | splinting/immob to prevent irritation, modalities - ice or superficial heat, maintain painfree ROM, avoid shoulder elevation ( similar to impingement) |
| bursitis MAX phase | PROM, below 80-90 deg, PRICE, theraband, modify ADL's |
| bursitis MOD phase | early, strengthening, theraband (rhomboids), no under 45 deg abd, fex, ext, IR, ER |
| what structure is responsible for stabilization of humerous? | bicipital tendon |
| How is the LHB affected by the RC? | if the RC is weak, puts more stress on LHB. |
| bicipital tendonitis is secondary to what activity? | overhead recurrent, repetitive |
| Speed's test | apply resist to 90 deg of shlder flex w/ER & elbow ext & supinated, + if pain, indicates tendonitis or fraying of LHB |
| Yergason's test | stablize pt's arm against body, flex elb to 90 deg, palpate bicipital tendon, have pt supinate & ER arm.....+ if pain or tester feels tendon slip out of groove |
| if someone has chronic pain, proximal area of shoulder, palpable tenderness in bicipital groove, pain w/resisted elbow flexion (flex after supination)....indicator of ? | bicipital tendonitis |
| bicipital tendonitis rehab | sometimes immob, bicep stretch, elbow & shoulder ext, ROM, isom, theraband, UBE, PNF patterns, isot, functional (throwing, swimming, work hardening, etc) in min prot use cable machine to bring up with both but lower w/involved arm (eccentric) |
| examiner holds pt's arm from behind in 90 flex, 40 deg horz add, max ir, if pain or popping? Patient horiz add & flexes their shldr against examiners manual resistance | labral tear |
| pt supine, arm fully abducted. examiner places one hand on posterior aspect of head of humerous, while other hand holds arm above elbow. first hand pushes anteriorly while other rotates humerus laterally......clunk heard or felt indicates? | capsular labrum integrity, labral tear |
| slap lesion | superior labrum anterior to posterior.....(tendon peels Superior Labrum Anterior to Posterior of the LHB) |
| why does it take longer to heal? | not vascularized |
| avoid in rehab for slap lesion | avoid bicep strengthening & stretching, avoid supination (wrist stg)/AROM shldr flex |
| rehab slap lesion | modalities to dec inflam & stimulate healing, maintain/gain ROM, strg ex to improve jt stability & restore jt biomechanics, proprioceptive ex (CKC), NSAIDS |
| shoulder capsular pattern | ER, ABD, IR |
| causes of adhesive capsulitis? | immob, trauma, insidious onset (most common), 70% female 40-60 y/o |
| Apleys scratch test for? | adhesive capsulitis |
| Adh capsulitis rehab modalities? | ice if constant pain, later heat to work to elongate |
| PT for adhesive capulitis | Jt mobs (resting position = 55 deg abd, 30 deg horz add), PROM, stretches, AAROM, Home program!, strg available range is very important, functional (take glasses off shelf & put back on, wk full ROM available) |
| Bankart lesion | tear in anteroinferior labrum, causes shoulder instability |
| shoulder instability more likely in what population? & what causes? | younger, active patients, Bankart leasion, Slap lesion |
| GH dislocation | abducted, ext rotation, extension......anterior dislocation most common position |
| what mm's offer stability to humerus | subscapularis, GH ligament, LHB |
| what is the most commonly dislocated jt in body? | GH (shoulder), often assoc w/RC tears (30-80%) |
| Anterior shoulder Apprehension test | test for anterior instability, place jt in slow abd & ER, if pt has a feeling like the shldr will dislocate, indacates unstable shldr |
| Posterior shoulder apprehension test | test by horizontally adducting the arm & IR while in 90 deg of flex |
| rehab for anterior dislocation | sometimes immob 3-6 wks (remove from exer), ER w/elbow at side, shoulder in resting position, abd 55 deg, horz add 30 deg |
| AVOID w/anterior shoulder dislocation | full ABD, ER, extension (worst position is 90 deg abd w/ER), don't ned to work on ROM, want them to tighten down |
| MAX phase, shldr dislocation | ice, estim, NSAIDS, elbow, wrist & hand st/motion |
| MOD phase shldr dislocation | pulleys, codman's, sub max isom first (add & IR), avoid stg in abd, ROM exercises, isom (0 deg of abd) |
| what to strengthen for anterior GH dislocation? | anterior compartmet, IR & add's for stability, pec major, teres major, RC, coracobrachialis, biceps, latissmus dorsi, subscapularis, assess scapulothoracic/scapulohumeral motion & stg as necessary |
| MOD-MIN phase ant shld dislocation | maintain jt play but avoid anterior glide, isot (focus s/b on pec major, adductors, internal rotators, theraband to begin shldr adduct & IR for ant dislo, UBE, CKC shldr st, LHB CREATES LOT OF STABILITY, BICEP CURLS |
| shoulder medial/internal rotators | latissimus dorsi, teres major, subscapularis, pec major |
| shoulder external rotators | supraspinatus, infraspinatus, teres minor |
Created by:
djbari
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