Lecture 6 - Disorders associated with passive stabilizing structures

Laxity
subluxation - self corrects
dislocation - needs to be put back in

abnormal motion of the GH that results in pain or sense of displacement

structural abnormality of the GH that results in dislocation or subluxation

Grade I - stretch to fibers no disturbance
Grade II - stretch with fiber tearing but not complete disruption
Grade III - complete failure

varus or valgus

capsule
labrum
Coracohumeral ligament
superior GH ligament

suprspinatus
infraspinatus
subscap
teres minor

middle GH ligament
Inferior GH ligament complex
geometry of humerus
geometry of glenoid
joint cohesion

serratus
trapezii
rhomboids
levator scapulae
pectoralis minor

limits anterior and inferior humeral translation with the arm at the side

limits anterior humeral translation with the arm at the side and up to 45 deg of abduction

ligament complex - with abduction beyond 45 deg the anterior band limits translation with ER and the posterior band limits translation with IR

landing on arm fixed laterally
external rotation (valgus torque)

landing on arm fixed medially
picking something up hurts

lateral bow with arm fixed

primary restraint to valgus torque

valgus torque >90 deg

reduce tensile forces
reinforce contractile structures
prevents distraction

keeps radius on humerus and ulna
restraint to varus and supination

keeps the radius on the ulna

humerus - ulna
stops ulna rotation off the humerus - excessive supination

Frequency - how often is dislocates
Etiology - traumatic or atraumatic and what positions make it worse
Direction - varus/valgus, sup/pronation; GH ant, post, inf
Severity - did you put it back or did someone else?

double jointed
I've always been flexible (hypermobile)

global laxity scores

other health conditions and refer for subsequent evaluation

Ehlers Danlos Syndrome
Marfin's syndrome
Leys-Dietz syndrome
-connective tissue structure disorders

Unidirectional
Ligament Injuries
Labral injuries - Bankart, SLAP
Boney Defect - Hill Sachs, Glenoid
likely macrotrauma

Unidirectional/Multidirectional
Ligament injuries
Labral injuries - Bankart, SLAP
Scapula Dyskinesis
Hypermobility (laxity)
Postural Deficits
Neuromusuclar control deficits

unidirectional or multidirectional
Scapula dyskinesis
Hypermobility
Postural deficits
Neuromuscular control deficits

Muscle Imbalance
Similar to RCRSP
Popping/clicking
Aching after activing

Tendinopathy
Microtrauma to labrum
Capsule/Ligament/deformation/plasticity

Ligament/Capsule
Labrum
Glenoid Injury

Ligament/Capsule
Labrum Injury
Muscle Injury/Tears

Pain >7/10
High Disability
Pain with rest and sleep disruption
Inability to tolerate Passive or Active ROM

Pain 4-6/10
Moderate Disability
Pain with movement either passive or active
May have intermittent sleep disturbance

Pain <3
Minimal disability
able to engage in active motion with pain/fatigue only after increased stress/load
poor functional capacity

Anterior

TUBS - Traumatic Unidirectional Bankart Surgery

loose joint where HH easily goes in and out
caused by paralysis (from stroke), RTC muscles are paralyzed so shoulder will dislocate in multiple directions

AMBRII - atraumatic multi directional instability in both shoulders responds to intensive rehabilitation if surgery necessary Inferior capsule shift

Excessive stress in ER, Abduction or extension

Ant GH ligaments (HAGL)
Anterior labrum - SLAP
RTC

pain and apprehension with motions stressing structures

traction stress
Overhead (FOOSH)

SGHL
coracohumeral ligament
inferior labrum
capsule
supraspinatus

pain and apprehension with motions stressing structures

stress in flexion, adduction, IR

post capsule
labrum
PB of IGHL
Teres Minor

pain and apprehension with motions stressing structures

generalized laxity, high demand labor

any or all supporting atructures, static and dynamic

often self dislocate
scapula instability

75%

tear or disruption of anterior inferior GH labrum

tear or disruption of posterior inferior GH labrum

glenoid fracture anterior inferior glenoid

contusion or compression fracture of humeral head
bruise on HH usually associated with dislocation
bleeding at the articular surface bc of impact of bone on labrum

superior labrum anterior posterior
top of labrum where biceps tendon anchors

frayed cartilage at the edge of the labrum

labrum tears away from the glenoid cavity

bucket handle section tears away from the glenoid cavity

slap lesion extends and tears the biceps tendon

type I and type II

type III and type IV

Macro - FOOSH
Micro - overhead throwing

MCL
pronator flexor group

macro - FOSH, fracture of radial head
micro - tendinopathy common extensor tendon

LCL
LUCL
Extensor supinator group
radial head

macro - FOOSH, overload with supination of forearm
micro - tendinopathy

LUCL
LCL
Ulnar nerve

High Velocity
Injury with sudden impact

postential for both MCL/LCL
anterior capsule
coronoid process
brachialis, brachial artery, and median nerve

medial elbow instability

lateral elbow

rule out red flags and identify yellow flags
in presence of atraumatic symptoms of shoulder or elbow instability, be sure that cervical spine not contributing factor

peripheral neuropathy shoulder or elbow

test of function
mobility assessment
muscle performance (shoulder and elbow)
Selective tissue tests

include postural assessment

Atraumatic - must inlude ROM and Joint play
in the presence of elbow instability GH IR and ER ROM
Traumatic - ROM

ST muscles
Atraumatic - RTC balance/endurance
Traumatic - ability of RTC and ST muscles to fire

extension, ER + abduction, Horizontal abduction

flexion, IR, Horizontal adduction

lateral must be tested
may be painful in pronation on the medial side (radius pushing on the ulna)

instability
labral

apprehension / relocation (anterior/posterior)
Load and shift
sulcus
hyperabduction test (>105 GH only)

crank
biceps load I,II
active compression (O'Brien's)
Resisted supination external rotation

Valgus stress test
Milking maneuver

varus stress test
prone push up in supination
chair push up in supination
lateral pivot shift test - pt needs to be unconscious

ASH test
Grip dynamometry

assesses endurance of RTCin varying positions of overhead

end point accuracy - the laser thingy

local joint receptors

local receptors

Age
-age of 1st dislocation prognostic for repeat dislocation if <20 yo
level of irritability
boney integrity - dislocation with fracture, if immobilized >2 weeks might never get better

psychosocial variables - mental health support
Level of irritability - neuroplastic: high
Understanding of disorder - low understanding = poorer prognosis
concomitant connective tissue disorders - prolonged recovery