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NPTE The Shoulder
Notes for NPTE
| Question | Answer |
|---|---|
| What is the resting position, close packed position, capsular pattern and non parttern of the glenohumeral joint? | 40-55 abduction, 30horizontal adduction (scapular plane)Full abduction, lateral rotationLateral rotation, abduction, medial rotationexternal rotation, abduction, flexion, internal rotation |
| Scapulohumeral rhythm | During 180 of abduction, there is roughly a 2:1 ration of movement of the humerus to the scapula, with 120 of movement occurring at the glenohumeral joint and 60 at the scapulothoracic joint. |
| What happen when you have a unstable shouder? | The Scapulohumeral rhythm is commonly altered because of incorrect dynamic functioning of the scapular or humeral stabilizers or both. This may be related to incorrect arthrokinematics at the glenohumeral joint |
| What happen when you have a reverse scapulohumeral rhythm? | The scapula moves more than the humerus. The patient appears to “hike” the entire shoulder complex rather than produce a smooth coordinated abduction movement. |
| In what way would you mobilize the GH joint to increase ABDUCTION? | INFERIOR CAUDAL |
| In what way would you mobilize the GH joint to increase Early flexion (0-45)? | Posterior |
| In what way would you mobilize the GH joint to increase internal rotation? | Posterior |
| In what way would you mobilize the GH joint to increase Horizontal adduction? | Posterior |
| In what way would you mobilize the GH joint to increase extension/lateral rotation? | Anterior |
| In what way would you mobilize the GH joint to increase horizontal abduction? | Anterior |
| In what way would you mobilize the GH joint to increase late flexion (120-180)? | anterior |
| What is the resting position, close packed position, capsular pattern of the acromioclavicular joint? | Arm by side90 abductionPain at extremes of range of motion, especially horizontal adduction and full elevation |
| Which branches innervated the acromiclavicular joint? | Branches of the suprascapular and lateral pectoral nerve |
| What is the resting position, close packed position, capsular pattern of the esternoclavicular joint? | Arm at sideFull elevation and protractionPain at extremes of range of motion, especially horizontal adduction and full elevation. |
| What can you tell about scapulothoracic joint? | Is not a true joint. The muscles acting on the scapula help to control its movements. It does not have a capsular pattern nor a close packed position. |
| Which muscles elevate the scapula? (2) | Upper trapeziusLevator scapulae |
| Which muscles depress the scapula? (4) | Serratus, pectoralis major & minor, latisimus, trapezius (lower fibers) |
| Which muscles protract the scapula? (3) | Serratus anterior, Pec major and minor |
| Which muscles retract the scapula? (2) | Trapezius, Rhomboids |
| Which muscles upwardly rotate the scapula? (3) | Upper and Lower traps, Serratus anterior |
| Which muscles downwardly rotate the scapula? (3) | Rhomboids, Levator scapulae, Pec major |
| Which muscles flex the shoulder? (5) | Anterior delt, Coracobrachialis, Pec major, Biceps, Supraspinatus |
| Which muscles extend the shoulder? (4) | Lats, Subscap, Post deltoid, Teres major |
| Which muscles abduct the shoulder? (3) | Middle delt, Supraspinatus, Infraspinatus |
| Which muscles laterally rotate the shoulder? (3) | Teres minor, Infraspinatus, Posterior delt |
| Which muscles medially rotate the shoulder? (5) | Subscap, Teres major, Pec major, Lats, Anterior deltoid |
| What is the function of the rotator cuff mucles? | They hold the head of the humerus in the glenoid cavity during abduction. |
| What happen when the supraspinatus is paralyzed? | Patient experiences no difficulty in raising the arm overhead, but a decrease in strength and endurance resulted. Loss of abd as seen in patients with rupture of the supraspinatus tendon is due to pain. |
| What happen when on of the abd muscles is paralyzed? | still can perform an unresisted motion of glenohumeral joint abd with the other, although the strength and functional use in abd is reduced. |
| But if both are paralyzed? | Shoulder abd is seriously affected. No true abd is then possible unless the shoulder is fully ext rot. |
| What is the fuction of Deltoid? | Pull the humerus up. |
| What happen when the deltoid is paralyzed? | Can not perform glenohumeral abd. Instedad, the arm is raised slightly by upward rot. of the scapula nd lateral flex of the trunk |
| How patients with isolated deltoid paralysis perfom abduction? | Patients with isolated deltoid paralysis can By ext rot. The glenohumeral joint (to use the biceps) and a slight motion toward flex at around 90 abd. |
| What is the function of the trapezius? | Cause upward rotation of the scapula during arm elevation.Support the shoulder girdle and prevent sagging of the shoulder |
| What happen when the trapezius is paralyzed? | The support is missing and the shoulder sloper down more than it would normally. The weight of the arm tends to draw the tip of the shoulder down, causing the scapula to rotate downward beyond its normal hanging position. |
| How can the shoulder girdle can be elevated even if the trapezius is paralyzed? | The levator scapulare and the rhomboids are caple of doing so without the aid of the upper trapezius. |
| What is the function of the serratus anterior? | Cause upward rotation of the scapula during arm elevation? |
| What happen when the serratus anterior is paralyzed? | The subject is unable to rise the arm over head as the trapezius cannot bring about enough upward rotation for complete abd. A typical WINGING is seen when it is paralyzed and the scapula fails to side forward on the rib cage. |
| What are the indications of loss of scapular control? | scapula protracting along chest wall,under load;early contraction of upper trapezius on abduction,under load; Increased work of rotator cuff and biceps, especially with closed chain activity (reverse oringin-insertion);Altered scapulohumeral rhythm |
| Who causes anterior humeral translation? | Weak subscapulares and teres major, tight infraspiatus and teres minor. |
| Who causes scapular winging fault on concentric elevation? | Long/weak serratus anterior |
| Who causes scapular winging fault on eccentric forward flexion? | Overactive rotator cuff; underactive scapular control muscles |
| Who causes scapular winging fault on tilting of inferior angle? | Tight pectoralis minor; weak lower trapezius. |
| Winging of the scapula cause: Trapezius or spinal accessory never lesion | Effect (signs and symptoms): Inability to shrug shoulder |
| Winging of the scapula cause: Serratus anterior or long thoracic nerve lesion | Effect (signs and symptoms): Difficulty elevating arm above 120 |
| Winging of the scapula cause: Strain of rhomboids | Effect (signs and symptoms): Difficulty pushing elbow back against resitance (with hand on hip). |
| Winging of the scapula cause: Muscle imbalance or contractures | Effect (signs and symptoms): Winging of upper margin of scapula on adduction and lateral rotation |
| Which muscles the spinal accessory nerve innervated? | Trapezius (shoulder elevation) |
| What happen when the Spinal accessory nerve (C1-C4) is affected? | Inability to abd arm beyond 900, pain in shoulder on abduction. |
| What sensory alteration occurs when spinal accessory nerve is affected? | Brachial plexus symptoms possible because of drooping of shoulder; and also shoulder aching. |
| What is the mechanism of injury of spinal accessory nerve? | Direct blow;Traction (shoulder depression and neck rotation to opposite side); Biopsy |
| Which muscles the long thoracic nerve (C5-C7) innervated? | Serratus anterior (scapular control) |
| What happen when the long thoracic nerve (C5-C7) is affected? | Pain on flexion fully extended arm, inability to flex fully extended arm, winging starts at 90 forward flexion |
| What is the mechanism of injury of long thoracic nerve? | Direct blow; Traction;Compression against internal chest wall (backpack injury);Heavy effort above shoulder height ;Repetitive strain |
| Which muscles the suprascapular nerve (C4-C6) innervated? | Supraspinatus, infraspinatus (arm lateral rotation) |
| What happen when the suprascapular nerve (C4-C6) is affected? | Increased pain on forward shoulder flexion, shoulder weakness (partial loss of humeral control). Pain increases with scapular abd and cervical rotation to opposite. |
| What sensory alteration occurs when suprascapular nerve (C4-C6) is affected? | Top of shoulder from clavicle to spine of scapula;Pain in posterior shoulder radiating into arm |
| What is the mechanism of injury of long thoracic nerve? | Compression in suprascapular notch;Stretch into scapular protraction plus horizontal adduction;Compression in spinoglenoid notch ; Direct blow; Space occupying lesion |
| Which muscles the axillary (circumflex) nerve (C5-C6) innervated? | Deltoid, teres minor (arm abduction) |
| What happen when the axillary (circumflex) nerve (C5-C6) is affected? | nability to abduction arm with neutral rotation. |
| What sensory alteration occurs when axillary (circumflex) nerve is affected? | Deltoid area; Anterior shoulder pain |
| What is the mechanism of injury of axillary nerve? | Anterior glenohumeral dislocation or fracture of surgical neck of humerus; Forced abduction; Surgery for instability |
| Which muscles the Musculocutaneous nerve (C6-C7) innervated? | Coracobrachialis, biceps, brachialis (elbow flexion) |
| What happen when the Musculocutaneous nerve (C6-C7) is affected? | weak elbow flexion with forearm supinated. |
| What sensory alteration occurs when Musculocutaneous nerve (C6-C7) is affected? | Lateral aspect of forearm |
| Is there any reflexes affected when musculocutaneous nerve is affected: | Biceps |
| What is the mechanism of injury of Musculocutaneous nerve (C6-C7) nerve? | Compression; Muscle hypertrophy; Direct blow; Fracture (clavicle and humerus); Dislocation (anterior);Surgery (Putti-Platt, bankart) |
| What is Yergason’s test used for? Describe it. | Integrity of transverse ligament and bicipal tendonitis. Patients sitting with shoulder in neutral stabilized against trunk, elbow at 90, and forearm pronated. Resist supination of forearm and external rotation of shoulder. |
| What is the positive find of Yergason’s test? | Tendon of biceps long head will “pop out” of groove. May also reproduce pain in long head of biceps tendon. |
| What is Speed’s (straight arm) test used for? Describe it. | Bicipal tendonitis or tendonosis. Patient sitting or standing with upper limb in full ext,forearm supinated. Resist shoulder flexion.May also place shoulder in 90 flexion and push upper limb into extension causing an eccentric contraction of biceps. |
| What is the positive find of Speed’s (straight arm) test? | Pain in long head of biceps tendon |
| What is Neer impingement test used for? Describe it. | For soft tissue structures of shoulder complex (long head of biceps and supraspinatus tendon). Patient sitting and shoulder is passively internally rotated then fully abducted |
| What is the positive find of Neer impingement test? | Pain within shoulder region |
| What is Supraspinatus (empty can) test used for? Describe it. | Tear and/or impingement of supraspinatus tendon or possible suprascapular nerve neuropathy. Patient sitting with shoulder at 90 and no rot. Resist shoulder abd. Then place shoulder in “empty can” position, int rot, 30 forward (horiz add) and resist abd, |
| What is the positive find of Supraspinatus (empty can) test? | Pain in supraspinatus tendon and/or weakness while in “empty can” position. |
| What is Drop arm test used for? Describe it. | Identifies tear/or full rupture of rotator cuff. Patient sitting with shoulder passively abducted to 120. Patient instructed to slowly bring arm down to side. Guard patient’s arm from falling in case it gives way. |
| What is the positive find of Drop arm test? | Patient unable to lower arm back down to side. |
| What is Posterior internal impingement test used for? Describe it. | Identifies an impingement between rotator cuff and greater tuberosity or posterior glenoid and labrum. Patient supine and move shoulder into 90o abduction, maximum external rotation, and 15 -20 horizontal adduction. |
| What is the positive find of Posterior internal impingement test test? | Pain in posterior shoulder during test. |
| What is Clunk test used for? Describe it. | Identifies a glenoid labrum tear. Identifies a glenoid labrum tear. |
| What is the positive find of Clunk test? | Audible “clunk” is heard while performing test. |
| What is Anterior apprehension sign test used for? Describe it. | Identifies past history of anterior shoulder dislocation. Patient supine with shoulder in 90 abduction. |
| What is the positive find of Anterior apprehension sign test? | Patient does not allow and/or does not like shoulder to move in direction to simulate anterior dislocation. |
| What is Posterior apprehension sign test used for? Describe it. | Past history of posterior shoulder dislocation. Patient supine with shoulder abd 9) (in plane of scapula) with scapula stabilized. Posterior force through shoulder via force on patient’s elbow while moving shoulder into med rot and horizontal adduction. |
| What is the positive find of Posterior apprehension sign test? | Patient does not allow and/or does not like shoulder to move in direction to simulate posterior dislocation. |
| What is Acromiclavicular shear test used for? Describe it. | Dysfunction of AC joint (such as arthritis, sepa. Patient sitting with arm resting at side. Examiner clasps hands and places heel of one hand on spine of scapula and heel of other hand on clavicle. Squeeze hands together causing compression of AC joint |
| What is the positive find of Acromiclavicular shear test? | Pain in AC joint. |
| What is Adson’s test used for? Describe it. | Identifies pathology of structures that pass through thoracic inlet. Patient sitting and find radial pulse of extremity being tested. Rotate head towards extremity being tested then extend and externally rotate the shoulder while extending head. |
| What is the positive find of Adson’s test? | Neurologic and/or vascular symptoms (disappearance of pulse) will be reproduced in upper extremity. |
| What is Costoclavicular syndrome (military brace) test used for? Describe it. | Identifies pathology of structures that pass through thoracic inlet. Patient sitting and find radial pulse of extremity being tested. Move shoulder into maximal abduction and external rotation. Move involved shoulder down and back. |
| What is the positive find of Costoclavicular syndrome (military brace) test? | Neurologic and/or vascular symptoms (disappearance of pulse) will be reproduced in upper extremity. |
| What is Wright (hyperabduction) test used for? Describe it. | Patient sitting and find radial pulse of extremity being tested. Move shoulder into maximal abduction and external rotation. Taking deep breath and rotating head opposite to side being tested may accentuate symptoms |
| What is the positive find of Wright (hyperabduction) test? | Neurologic and/or vascular symptoms (disappearance of pulse) will be reproduced in upper extremity. |
| What is Upper limb tension test used for? Describe it. | Evaluation of peripheral nerve compression. Neurologic symptoms will be reproduced in upper extremity. |
| What is the history of rotator cuff lesions? | Age 30-50 years; pain and weekenss after eccentric load |
| What can you observe in rotator cuff lesions? | Normal bone and soft tissue outlines; protective shoulder hike may be seen |
| What happen when you have active movements in rotator cuff lesions? | Weakness of abduction or rotation, or both; crepitus may be present |
| What are the passive movements of? | Pain if impingement occurs |
| What resisted isometric movements are present in rotator cuff lesions? | Pain and weakenss on abduction and lateral rotation |
| What are the special test for rotator cuff lesions ? | Drop-arm test, Empty can test |
| Is the sensory function or reflexes are affected in rotator cuff lesions? | Not affected |
| What the palpation exam in rotator cuff lesions will show? | Tender over rotator cuff |
| What the diagnostic imaging of rotator cuff lesions will show? | Radiography: upward displacement of humeral head; acromial spurring, MRI diagnostic |
| What is the history of Frozen shoulder? | Age 45+ (insidious type); insidious onset or after trauma or surgery; functional restriction of lateral rotation, abduction, and medial rotation. |
| What can you observe in Frozen shoulder? | Normal bone and soft-tissue outlines |
| What happen when you have active movements in Frozen shoulder? | Restricted ROM, shoulder hiking |
| What are the passive movements of Frozen shoulder? | Limited ROM, especially in lateral rotation, abduction, and medial rotation (capsular pattern) |
| What resisted isometric movements are present in Frozen shoulder? | Normal, when arm by side |
| What are the special test for Frozen shoulder? | None |
| Is the sensory function or reflexes are affected in Frozen shoulder ? | Not affected |
| What the palpation exam in Frozen shoulder will show? | Not painful unless capsule is stretched |
| What the diagnostic imaging of Frozen shoulder will show? | Radiography negative; Arthrography decreased capsular size |
| What is the history of Atraumatic instability? | Age 10-35 years; pain and instability with activity; no history of trauma |
| What can you observe in Atraumatic instability? | Normal bone and soft-tissue outlines |
| What happen when you have active movements in Atraumatic instability? | Full of excessive ROM |
| What are the passive movements in Atraumatic instability? | Normal or excessive ROM |
| What resisted isometric movements are present in Atraumatic instability? | Normal |
| What are the special test for Atraumatic instability? | Augmentation tests positive |
| Is the sensory function or reflexes are affected in Atraumatic instability? | |
| What the palpation exam in Atraumatic instability will show? | Anterior or posterior pain |
| What the diagnostic imaging of Atraumatic instability will show? | Negative |
| What is the history of Cervical spondylosis? | Age 50+ years; acute or chronic |
| What can you observe in Cervical spondylosis? | Minimal or no cervical spine movement; torticollis may be present |
| What happen when you have active movements of Cervical spondylosis? | Limited ROM with pain |
| What are the passive movements of Cervical spondylosis? | Limited ROM (symptoms may be exacerbated) |
| What resisted isometric movements are present in Cervical spondylosis? | Normal, except if nerve root compressed; myotome may be affected |
| What are the special test for ? | Spurling’s test,Distraction test ,ULTT positive, Shoulder abduction test |
| Is the sensory function or reflexes are affected in Cervical spondylosis ? | Dermatomes affected; reflexes affected |
| What the palpation exam in Cervical spondylosis will show? | Tender over appropriate vertebra of facet |
| What the diagnostic imaging of Cervical spondylosis will show? | Radiography: narrowing osteophytes |
| What are the symptoms of Exernal primary impingement (stage I)? | Intermittent mild pain with overhead activities. Over age 35 |
| What are the symptoms of Exernal primary impingement (stage II? | ) Mild to moderate pain with overhead activities or strenuous activities |
| What are the symptoms of Exernal primary impingement (stage III)? | Pain at rest or with activities; night pain may occur; scapular or rotator cuff weakness is noted |
| What are the symptoms of Rotator cuff tear (full thickness)? | Classic night pain; weakness noted predominantly in abduction and lateral rotators; loss of motion |
| What are the symptoms of Adhesive capsulitis (idiopathic frozen shoulder)? | Inability to perform activities of daily living owing to loss of motion; loss of motion may be perceived as weakness |
| What are the symptoms of Anterior instability (with or without external secondary impingement)? | Apprehension to mechanical shifting limits activities; slipping, popping, or sliding may present as suitable instability; apprehension usually associated with horiz abd and lat rot; anterior or posterior pain may be present; weak scapular stabilizers |
| What are the symptoms of Posterior instability? | Slipping or popping of the humerus out the back; this may be associated with forward flexion and medial rotation while the shoulder is under a compressive load. |
| What are the symptoms of Multidirectional instability? | Looseness of shoulder in all directions, this may be most pronounced while carrying luggage or turning over while asleep; pain may or may not be present. |
| What is the prevalence of Overuse tendinosis? | Common |
| What is the time for recovery, early presentation of Overuse tendinosis? | 6-10 weeks |
| What is the time for full recovery ,chronic presentation of Overuse tendinosis? | 3-6 months |
| What is the likelihood of full recovery to sport from chronic symptoms of Overuse tendinosis? | 80% |
| What is the focus of conservative therapy in Overuse tendinosis? | Encouragement of collagen-synthesis maturation and strength |
| What is the role of surgery in Overuse tendinosis? | Exercise abnormal tissue |
| What is the prognostic for surgery in Overuse tendinosis? | 70-85% |
| What is the time for recovery from surgery in Overuse tendinosis? | 4-6 months |
| What is the prevalence of Overuse tendinitis? | Rare |
| What is the time for recovery, early presentation of overuse tendinitis? | Several day to 2 weeks |
| What is the time for full recovery ,chronic presentation of ? | 4-6 weeks |
| What is the likelihood of full recovery to sport from chronic symptoms of overuse tendinitis? | 99% |
| What is the focus of conservative therapy in overuse tendinitis? | Anti-inflammatory modalities and drugs |
| What is the role of surgery in overuse tendinitis? | Not known |
| What is the prognostic for surgery in overuse tendinitis? | 95% |
| What is the time for recovery from surgery in overuse tendinitis? | 3-4 weeks |
| Is Night pain present in Anterior painful arc? | yes |
| In wich sex is more like to have anterior painful arc? | F>M |
| The pain in the anterior painful arc is aggravated by? | Lateral rotation and abduction |
| Where is located the Tenderness in anterior painful arc? | Lesser tuberosity |
| Is there Acromioclavicular joint involvement in anterior painful arc? | No |
| Is Calcification present in anterior painful arc? | supraspinatus, infraspinatus and/or subscapularis |
| Is there a Third-degree strain biceps brachii (long head) present in anterior painful arc? | no |
| What is the Prognosis in anterior painful arc? | good |
| Is Night pain present in Posterior painful arc? | yes |
| In which sex is more like to have Posterior painful arc? | F>M |
| The pain in the posterior painful arc is aggravated by? | Medial rotation and abduction |
| Where is located the Tenderness in posterior painful arc? | Posterior aspect of greater tuberosity |
| Is there Acromioclavicular joint involvement in posterior painful arc? | No |
| Is Calcification present in posterior painful arc? | Supraspinatus and/or infraspinatus |
| Is there a Third-degree strain biceps brachii (long head) present in posterior painful arc? | no |
| What is the Prognosis in posterior painful arc? | Very good |
| Is Night pain present in Superior painful arc? | maybe |
| In which sex is more like to have Superior painful arc? | M>F |
| The pain in the Superior painful arc is aggravated by? | Abduction |
| Where is located the Tenderness in Superior painful arc? | greater tuberosity |
| Is there Acromioclavicular joint involvement in Superior painful arc? | often |
| Is Calcification present in Superior painful arc? | supraspinatus and/or subscapularis |
| Is there a Third-degree strain biceps brachii (long head) present in Superior painful arc? | Occasional |
| What is the Prognosis in Superior painful arc? | Poor without surgery |
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