How much AP translation of the GH joint?
How much sup-inf traslation of the GH joint?
What is the primary restraint to AP clavicular translation at the SC joint?
Posterior capsular ligament
What is normal ROM of the SC joint?
- Elevation - 45
- Depression - 10
- Protraction - 30
- Retraction - 30
- Rotation - 15-40
At what amount of GH range does SC movement primarily occur?
Below 90-10 deg
What is the primary restraint to posterior translation at the AC joint?
Superior & inferior capsular lig
What AC joint motion does the conoid lig resist?
Clavicular elevation, protraction, superior and anterior displacement.
What AC joint motion does the trapezoid lig resist?
Compression, and is also a secondary restrain to elevation and protraction.
What are the 4 scapulothoracis exercises recommended?
- 1. Scaption with thumb up
- 2. Press down
- 3. Push-up with pluss
- 4. Retraction
What are the 4 glenohumeral exercises recommended?
- 1. Scaption with thumb up
- 2. Press down
- 3. Flexion with thmb up (to 90deg)
- 4. Prone ER with horizontal extension (prone horizontal abd with ER)
What is the normal ration of IR:ER and what is it in a posterior dominant shoulder?
- Normal = 66%
- Posterior dominant shoulder = 76%
List the cluster of signs for impingement.
- Lateral pain
- Pain with overhead lifting/painful arc
- Pain at night
- Compensatory shrug
- >40 yo
List the cluster of signs for full-thickness tear of rotator cuff.
- Functional disability
- Pain: lateral; dull, constant ache; night; awakens
- Compensatory shrug
- >40 yo
Describe the treatment of a stage 1 rotator cuff.
Inflammation, edema, hemorrhage (pt usually < 25 yo
- Anti-inflam techniques (ice, phono, HVE, NSAIDs, ionto)
- Joint mobiliztions: posterior and inferior as capsular tightness dictates
- Dynamic stabilization drills
Describe the treatment of a stage 2 rotator cuff.
Lesion progresses to fibrosis and RC tendonitis ( pt usually <25-40 yo)
- Use healing treatments (MHP, cont US, transverse friction)
- Exerisse: eccentrics, dynamic stabilization
- Joint mobs: posterior and inferior as capsulra tightness dictates
Describe the treatment of a stage 3 rotator cuff.
Formation of bone spurs, tendon failure (pt usually >40 yo)
- Healing treatments (MHP, Cont US, transverse friction massage)
- Exercise: eccentrics, dynamic stabilization
List considerations of an arthroscopic rotator cuff repair.
- usually single-row fixation which leads to reduced fixation strength
- Less pain & stiffness
- Rehab more cautiosly
List considerations of an open rotator cuff repair.
- Double-row fixation - usually stronger
- More pain
List considerations of an arthroscopic with double row fixation rotator cuff repair.
- May allow for more progressive rehab
What is important about early rotator cuff repairs?
Early repairs have greater stiffness post op - progressed more quickly
What is important about later rotator cuff repairs?
have less inflammation - progressed more conservatively
List the cluster signs of biceps involvement.
- Tenderness over intertubercular sulcus - most common symptom
- Pain moves laterally with ER
- Pain will radiate into muscle belly
- MOI: eccentric deceleration activities
What are the three typs of biceps involvement?
What are the positives and negatives of a biceps tenodesis?
- Better cosmesis
- Better supinator strength (8% deficit)
- Longer recovery
- Used in active patients <55 yo
What are the positives and negatives of a biceps tenotomy?
- Preferred method
- Faster return to work
- Equivalent elbow flexion strength
- Supinator strength deficit (21%)
Describe a type I SLAP tear.
- - fraying and degeneration of the superior labrum, normal biceps (no detachment);
- - most common type of SLAP tear (75% of SLAP tears);
- - often associated with rotator cuff tears;
- - these are treated w/ debridement;
Describe a type II SLAP tear.
- detachment of superior labrum and biceps insertion from the supra-glenoid tuberlce;
- - when traction is applied to the biceps, the labrum arches away from the glenoid;
- - typically the superior and middle glenohumeral ligaments are unstable;
- - may resemble a normal variant (Buford complex);
- - 3 subtypes: based on detachment of labrum involved anterior aspect of labrum alone, the posterior aspect alone, or both aspects;
- - posterior labram tears may be caused by
- impingement of cuff against the labrum with the arm in the abducted and
- externally rotated position;
- - as noted by Tae Kyun Kim et al. type-II lesions in patients older than 40 years of age were associated with a supraspinatus tear where as
- in patients younger than 40 years were associated
- with participation in overhead sports and a Bankart lesion;
- - treatment involves anatomic arthroscopic repair;
Describe a type III SLAP tear.
- - bucket handle type tear;
- - biceps anchor is intact;
Describe a type IV SLAP tear.
- - vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps (intrasubstance tear);
- - may be treated w/ biceps tenodesis if more than 50% of the tendon is involved;
These types of SLAP lesions are debrided.
Type I and III
These types of SLAP lesions are repaired.
Type II and IV
List the cluster of signs of a SLAP lesion.
- Vague deep joint pain
- History of macrotrauma: force that pushes the humeral head over or away from the superio rlabrum
- History of deceleration activites/overhead cocking position
- Complaint of locking, popping, catching
What is the most sensitive image to detect a SLAP lesion?
Gadolinium MRI because dy extravasates into labrum tears.
Describe primary adhesive capsulitis (idiopathic)
- Insidious, rogressive, global loss of AROM & PROM
- Affects joint capsule and GH ligs (not muscle or fascia)
Describe secondary adhesive capsulitis.
- Acquired (post surgical, post traumatic)
- Afects joint, capsulre, GH ligs and extra-articular tissues and fascia
What is the capsular pattern of the shoulder?
ER, Abduction, IR
List the cluster of signs of adhesive capsulitis.
- Sulcus sign at 0 deg (superior capsule/ligs)
- Sulcus sign at 90 deg (inferior capsule/ligs)
- Anterior load and shift
- Posterior lad and shift
What is the time frame and findings of adhesive capsulitis in stage I?
- 0-3 months
- Progressive pain
- Global loss of AROM & PROM due to pain
- Arthroscopy reveals hypertrophic vascular synovitis
What is the time frame and findings of adhesive capsulitis in stage II?
- 3-9 months
- Persistent pain
- Progressive loss of ROM (due to pain & reduced capsular volume)
- Arthroscopy reveals dense hypervascular synovitis, perivascular scar formation, capsular fibroplasia, disorganized collagen fibrils, NO inflammatory infilitrates
What is the time frame and findings of adhesive capsulitis in stage III?
- 9-14 months
- Reduced pain
- Significant global ROM limitations (due to capsular fibrosis and decreased capsular volume)
- Arthroscopy reveals unremarkable, patches of synovial thickening, no evidence of hypervascularity, presence of dense hypercellular collagenous tissue.
What is the time frame and findings of adhesive capsulitis in stage IV?
- Greater than 14 months
- Similar to stage III
What are the precuations of a stage I adhezive capsulits?
Avoid aggressive ROM and joint mogs as these can potentially accelerate disease process and not needed as histologic changes have not occured.
For what stages of adhesive capsulitis is a steroid injection appropriate?
Stage I and II