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138 Cards in this Set

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  • Back
Sternoclavicular is what type of joint
saddle joint
clavicle is S shaped with the anterior surface concave where
convex medially and concave laterally
long axis of clavicle
superior to horizontal plane and 20 deg posterior to frontal plane
two landmarks of inferior surface of medial clavicle
costal facet (rests on first rib) and costal tuberosity (costalclavicular lig)
two landmarks of inferior surface of lateral clavicle
conoid tubercle (conoid lig) and trapezoid line (trapezoid lig)
describe the head of the humerus
convex, 135 deg angle of inclination and retroverted about 30 deg related to med-lat axis through elbow
landmarks of the humerus
head, neck, greater tubercle, lesser tubercle, intertubercular groove, deltoid tuberosity, radial goove
attachment of supraspinatus
upper facet of greater tubercle
attachment of infraspinatus
middle facet of greater tubercle
attachment of teres minor
lower facet of greater tubercle
attachment of pectoralis major
crest directly inferior to greater tubercle
attachment of subscapularis
lesser tubercle
attachment of teres major
crest directly inferior to lesser tubercle
what runs in the intertubercular groove and what attaches to it's floor
long head of bicep and latissimus dorsi, respectively
where is the radial groove and what does it separate
obliquely across the posterior surface and separates the origin of medial and lateral heads of tricep
superior medial angle of scapula sits where and has what muscle attachment
level of rib 2 and insertion of levator scapulae
root of the spine of the scapula sits where
about T3
inferior angle of scapula sits here
level of rib 7 (some have insertion of lats)
three types of acromions and prevalence of each
I - flat - 19%
II - curved - 42%
III - hooked - 39%
orientation of glenoid fossa
tilted superiorly 5 deg and 35 deg anterior to frontal plane
what lig makes suprascapular notch a hole
transverse scapular lig
3 true joints and 1 funtional joint of the shoulder
SC, AC, and glenohumeral
scapulothoracic
location of scapula in relation to thorax; and where it gets stability
between ribs 2 and 7, about 2.5 inches from spinous processes; muscular components
what do protraction and retraction fascilitate
dissipate forces (catching and throwing a ball)
what lig makes suprascapular notch a hole
transverse scapular lig
3 true joints and 1 funtional joint of the shoulder
SC, AC, and glenohumeral
scapulothoracic
location of scapula in relation to thorax; and where it gets stability
between ribs 2 and 7, about 2.5 inches from spinous processes; muscular components
what do protraction and retraction fascilitate
dissipate forces (catching and throwing a ball)
SC joint description
synovial saddle joint, close packed is full posterior rotation
medial clavicle - convex ______ and concave _______
along longitudinal diameter; along transverse diameter
articular disc serves what purpose
shock absorber, increase surface area of joint
stabilizing structures of SC joint
joint capsule, anterior and posterior SC lig, interclavicular lig, costoclavicular lig (1st rib to costal tuberosity, w/ 2 bundles)
ROM in SC: elevation/depression, protraction/retraction, rotation
45 deg elevation to 10 deg depression, 15-30 deg, 40-40 deg
4:10:90 rule
4 deg of rotation for every 10 deg of elevation (up to 90 deg)
description of AC joint
plane joint, close packed position is complete upward rotation
stabilizing structures of AC joint
AC lig, coracoclavicular lig (trapezoid - coracoid to trap line, conoid - coracoid to conoid tubercle), articular disc
motions of the AC joint: upward/downward rotation, horizontal plane adjustments, sagittal plane adjustments
as scapula swings up and out (up to 30 deg), medial border of scapula pivots away/toward thorax, inferior angle of scapula pivots away/toward thorax
stabilizing structures of glenohumeral joint
fibrous capsule, glenohumeral lig's, coracohumeral lig, rotator cuff, glenoid labrum, static forces
fibrous capsule
rim of glenoid fossa to anatomical neck; has synovial lining
volume of capsular space
2x humeral head
glenohumeral lig's - how many and where to they support
three bands (superior, middle, and inferior) that support anterior and inferior portions of capsule
superior glenohumeral lig
supraglenoid tubercle to anatomic neck above lesser tubercle; taught in full adduction and/or inferior posterior humeral translationg
middle glenohumeral lig
superior and middle anterior rim of glenoid fossa to anterior aspect of anatomic neck (blends w/subscap and capsule); resists anterior humeral translation and external rotation
inferior glenohumeral lig
anterior and inferior rim of glenoid fossa to anterior inferior/posterior inferior anatomic neck; three bands (anterior, posterior, axillary pouch); taught in abduction (ant in abd and ER, post in abd and IR)
coracohumeral lig
lateral coracoid process to anterior side of greater tubercle (blends w/ supraspinatus); taught in end range ER, flex/ext and inferior translation of humerus
rotator cuff
subscap (anterior capsule), supra (superior capsule), infra and teres (posterior capsule)
glenoid labrum
fibrocartilagenous rim of fossa, accounts for 50% of depth (increases stability); long head of bicep originates as ext of labrum; named in zones like a clock (zone I @ 12, II @ 3, III @ 6, IV @ 9)
static forces
neg intraarticular pressure plus inclination of fossa with tension in superior capsular structures
motions of glenohumeral joint
flex/ext, abd/add, horizontal abd/add, ER/IR
coracoacromial arch function
serves as roof of glenohumeral joint, "protects" rotator cuff
what runs in coracoacromial arch
supraspinatus muscle and tendon, subacromial bursa, long head of bicep, portion of superior capsule
affects on subacromial space
posture, osteophyte formation, AC joint degeneration, hypertrophy of coracoacromial lig, inflammation of structures in it
number of bursa around shoulder
varies by author, but freq 8
bursa function and examples
decrease friction between tendons, capsules, and bone; subacromial, subdeltoid, subcoracoid, subscapularis,infraspinatus, scapular
3 muscle groups that provide synchronous movement patterns
humeral protectors - rotator cuff and long head of bicep
scapular pivoters - LS, UT, LT, rhomboids
humeral positioners - delt, pec major, lat
humeral protectors function
dynamically oppose the force of delt to approximate and depress humeral head
scapular pivoters function
scapular stabilization (body of crane), humerus (boom); body must be solid for boom to move
deltoid
axillary n, C5-6
pec major
med and lat pectoral n, C5-6
lat dorsi
thoracodorsal n, C6-8
Force Couples in shoulder?
RC/deltoid - abduction
UT/upper serratus - forward flex above 90 deg
LT/lower serratus - forward flex below 90 deg
scapulohumeral rhythm
full forward flexion, 120 deg elevation occurs at GH w/ last 60 deg assist of scapular rotation
janda's shoulder crossed phenomenon
tight - UT, levator scapulae, pecs, upper cervical extensors, SCM, scalenes, and teres'
inactive - MT, LT, rhomboids, serratus ant, dorsal neck flexors, subscap, supraspinatus, infraspinatus
innervation for anterioinferior capsule
axillary nerve (referred pain to delt and teres minor)
innervation for superior and posterior capsule
suprascapular nerve (referred pain to supra/infraspinatus)
innervation for superioanterior capsule
lateral pectoral nerve (referred to pec major)
scapular winging caused by damage to what
long thoracic nerve (C5-8)
loss of retraciton and downward rotation caused by what
damaged dorsal scapular nerve (C5-6); levator scapulae and rhomboids
suprascapular nerve (C5-6) innervates what
supraspinatus and infraspinatus
postural dysfunction (tight pec minor) can cause what
impingement of cords from brachial plexus
three places subclavian/axillary artery can be compromised
between: middle and anterior scalenes, clavicle and 1st rib, pec minor and upper ribs
compression of posterior circumflex humeral artery happens here
quadrilateral space (triceps long head, teres major and minor, and humerus)
close packed position of glenohumeral joint; loose packed position
full frontal abduction with full ER; 20 deg scapulohumeral abduction
joint play motions that happen in all movements
Scapulothoracic - distraction; AC - inf/ant glide, sup/post glide; GH - lateral distraction
Joint play motions for shoulder ER
Scapulothoracic - distraction,retraction, depression; AC - inf/ant glide, sup/post glide; SC - post glide; GH - lateral distraciton, ant glide
Joint play motions for shoulder IR
scapulothoracic - distraction, rotation, elevation; AC - inf/ant glide, sup/post glide; SC - ant glide; GH - lateral distraction, post glide
Joint play motions for horizontal adduction
scapulothoracic - distraction, protraction, elevation; AC - inf/ant glide, sup/post glide; SC - ant glide, inf glide; GH - lateral distraction, post glide
Joint play motions for horizontal abduction
scapulothoracic - distraction, retraction, elevation; AC - inf/ant glide, sup/post glide; SC - post glide, inf glide; GH - lateral distraction, ant glide
Joint play motions for sagittal flexion
scapulothoracic - distraction, upward rotation, elevation; AC - inf/ant glide, sup/post glide; SC - inf glide, ant glide; GH - lateral distraction, inf glide, post glide
Joint play motions for extension
scapulothoracic - distraction, retraction, depression; AC - inf/ant glide, sup/post glide; SC- sup glide, post glide; GH - lateral distraction, ant glide
Joint play motions for GH frontal abduction
scapulothoracic - distraction, rotation, elevation; AC - inf/ant glide, sup/post glide; SC - inf glide, post glide; GH - lateral distraction, inf glide, ant glide
static components adding to stability of shoulder
orientation of glenoid fossa, acromion, coracoid, labrum, capsuloligamentous complex, negative intra-articular pressure
dynamic components adding to stability of shoulder
rotator cuff, scapulothoracic posture and function
specific techniques for tx of pain, muscle guarding, inflammation
long arm tractoin/distraction; distal to proximal humeral effleurage; grade I-II GH oscillations; modalities (ice,US,MHP,e stim)
decreased ROM of shoulder - commonly tight structures
upper trap and levator scapulae, pec minor and major, teres major and minor, lat
specific techniques for tx of decrease ROM
GH joint accessory motions (inf glides, PA and AP glides, long arm distraction); scapulothroacic joint (sup/inf glide, rotation, protraction/retraction); AC/SC joints (AP and PA glides)
cervicothoracic mobility should be addressed, why?
stiff upper spine leads to foward shoulders and impingement
tx of decreased strength and joint hypermobility
upper quarter postural correction, general strengthenging, proprioception, postural integration, specificity training, sesation re-integration
three types of GH instability
ant, post, multidirectional
mechanism of GH instability
acute trauma or repetitive microtrauma
differential diagnosis for GH instability
RC tear, labral tear, hmeral fx, AC joint sprain
signs/symptoms of GH instability
pain w/overhead mov't or end range mov't, ER > IR (pain), positive apprehension test, may have muscle guarding, TRAUMA (could be minor), excessive motion in direction of instability, ROM decreased acutely and increased chronicaly, decreased strength
tx of instability
Stage I - complete rest (some AROM, ER blocked at 0-30), postural ed and scapular exercise, isometrics in neutral GH position
Stage II - progress ROM and mob's, mutliple angle isometrics in pain free range (advance as pt tolerates)
Stage III - classical strengthening, proprioception and endurance, funcitonal bracing for return to activity
two types of impingement
direct - structures compressed by other structures
indirect - associated w/instability at GH joint
mechanism of impingement
faulty posture and mechanics, predisposing anatomical problems (multiple factors)
Neer's classification of impingement syndromes
Stage I - under 25 years old, must have trauma, localized/reversible; edema and hemorrhage in supraspinatus tendon
Stage II - 25-40 years old, diffuse/irreversible; fibrosis and thickening of bursa/tendon (painful arc)
Stage III - over 40 years old, irreversible; degeneration/attrition of biceps/supraspinatus w/partial to full thickness tears
signs/symptoms of impingement
deep pain (in shoulder), limited ROM w/pain @ end range, tender to palpation, CANNOT SLEEP ON THAT SIDE or HAH, decrease inf glide and decreased MMT w/pain, painful arc (90-120)
tx of impingement
Stage I - education to avoid reinjury, gentle ROM/stretches and adress postural problems
Stage II - isometrics, reduce musle tone w/massage, fix arhtrokinematic motion, train to decrease instability
Stage III - friction massage if subacute or chronic, strengthen, NM control, joint mob's
mechanism of RC tear
> 35 year old - under use and poor blood supply, repetitive overhead work, introduce new activity
< 35 year old - actue trauma or microtrauma, fall on outstretched arm

(Often present early on as impingement)
signs/symptoms of RC tear
decrease ROM and strength, substitution patterns, purse/bra straps are painful, usually one event (even in degeneration), painful arch, drop arm test
tx of RC tear
Stage I - educate on tissue healing and activity modification, PROM to AAROM to AROM
Stage II - isometric strengthening and grade III-IV mob's
Stage III - dynamic motor control and specificity training
what to do w/pre-op pt w/RC tear
PNF of scapula and muscle activiation
things to discuss w/surgeon RE: RC tear
size of tear (small < 1cm, medium 1-3 cm, large 3-5 cm); # of tears; integrity of tissue/blood supply; type of delt resection
rehab post RC surg.
PROM/scapular stabilization 0-3 wks
AAROM/NM re-ed/postural training 3-6 wks
AROM/proprioception < 90 from 6-12 wks
proprioception/functional training 12 wks - 6 mos
mechanism of AC sprain
direct blow (fall on tip of shoulder) or fall on outstretched arm
diff diagnosis for AC sprain
impingement syndrome, labral tear, shoulder instability, RC pathology
grades of AC sprain
grade I - mild sprain of joint capsule and coraclavicular lig
grade II - rupture of capsule/sprain to coraclavicular lig
grade III - rupture capslue and coraclavicular lig
signs/symptoms of AC sprain
pain w/palpation, trauma, active when young, step up @ joint, improve posture due to distraction, pruising could mean clavicle fx, weak w/compensation patterns
tx of AC sprain
Stage I - postural ed, taping acromion to delt (decrease pain and increase function), PROM to AAROM to AROM below 90 deg flex (painfree)
Stage II - PROM above 90 deg flex, AROM/PNF/resistive motor control training, grade II-IV scapulothoracic/GH joint mob's, AC joint mob's only in chronic
Stage III - dynamic motor control training at GH and ST joints
mechanism of adhesive capsulitis
idiopathic, increased chance w/diabetic's and post menopausal women; look for trauma to r/o fx
signs/symptoms of adhesive capsulitis
decrease ROM/joint play, hard end feel, gradual (freezing,frozen,thawing)
tx of adhesive capsulitis
explain probable course, posture training, assess effects of grade I-II mob's, emphasize HEP and painfree AAROM
Scalene block before PT
mechanism of humeral fx
fall on outstretched arm in those older than 50
signs/symptoms of humeral fx
can't put on deodorant, no arm above head
neer's four segment fx classification
articular segment/anatomic neck, greater tuberosity, lesser tuberosity, humeral shaft (can have multiple)
complications of humeral fx
damage to axillary nerve or artery (check sensation)
tx of humeral fx
Stage I - immobilize for 4-12 wks, painfree PROM (avoid stress to fx site)
Stage II - grade II-III mob's, AAROM (painfree), scapular stabilization
Stage III - grade IV mob's, endurance training
tissue involved in snapping scapula
inflammed bursa (between: subscap and serratus, serratus and thorax); rib malformation; cysts deep to scapula
mechanism and characteristics of snapping scapula
repetitive overhead mov't, altered ST and GH rhythm, hx of trauma/surgery, osteochondroma, lushkas tubercles, poor posture, gradula onset
tx of snapping scapula
rest, activity modification, scapula/rib/soft tissue mobility, postural retraining, strengthening, NM reeducation
calcium deposits that cause calcific tendonitis are made of...
Ca phosphate, oxalate, carbonate
most freq involved tendon for calcific tendonitis
supraspinatus (secondary to stretch tendon over humeral head and repeat stress from contact w/acromial arch)
presentation of clacific tendonitis
25-60 yrs old, lots of overhead work, freq manipulation of tools
three phases of calcific tendonitis
Silent phase - incidental finding on x-ray, deposits may enlarge as one or multiple masses or absorb painlessly
Impingement phase - painful arc (60-120 deg), pain w/sleep on involved side, pain w/overhead activity and muscle contraction
Acute/Recurrent phase - pain at rest, guarding arm at side, unable to sleep, inflamed/warm/tender to light touch
diagnosing calcific tendonitis
cyriax positions (palpation), special tests (impingement), painful arc, imaging
tx of calcific tendonitis
PRICE, sling, subacromial corticosteroid injection, puncture Ca deposit
origin and path of suprascapular nerve
upper trunk of plexus, from C5-6; runs through post triangle of neck (under upper trap and omohyoid), through suprascapular notch (covered by transverse scapular lig), through spinoglenoid notch
sources of suprascapular nerve entrapment
compression by transverse scapular lig, traction to shoulder, overuse injury, carrying load on shoulders, blunt trauma to supraclavicular fossa, surgery, bony anomalies
presentation of suprascapular nerve injury
acute - pain, burning, numbness in GH joint or post lat scapula
subacute/chronic - more weakness than pain (scooped out deformity)
exam findings for suprascapular nerve
decrease AROM w/elevation (full PROM), weak abd and ER, passive shoulder horizontal add can tense nerve and cause pain
tx of suprascapular nerve injury
1-5 mm/day axonal sprouting, tx to maintain ROM and restore ST mobility/stability
origin and path of long thoracic nerve
ventral rami of C5-7, deep to plexus and clavicle but over rib 1, along lat aspect of thorax to serratus
MOI for long thoracic palsy
blow to lat thoracic wall/shoulder, lie motionless for long time, surgical complication (mastectomy, rib 1 resection, poor position), repetitive use (cycling, assembly line)
test function of long thoracic nerve
push-up (start at wall with pt's in pain)
exam findings w/long thoracic palsy
decreased AROM into elevation (medial border wings away), PROM is full, stretch of nerve may cause pain
tx of long thoracic palsy
usually conservative (recovery up to 2 years after injury), postural re-ed./ROM/strengthen noninvolved muscles
strength ratios at the shoulder
add to abd - 2:1
IR to ER - 3-2
ext to FF - 2-1
cyriax positions
supraspinatus - HBB palpate sup facet of humeral head
infraspinatus - arm in 90 deg FF elbow flex, load humerus post through elbow, palpate middle facet of humeral head
teres minor - same as infra, palpate inferior facet of humeral head
subscap - hand on thigh humerus abd/IR, palpate deep to pec major (superiorly)