Because the normal joint is sealed, attempted distraction of the joint surfaces lowers the intra-articular pressure even more, progressively adding substantial resistance to greater displacement. Intra-articular pressure is compromised with arthrography, arthroscopy, articular effusions, hemarthrosis, and in other situations in which free fluid is present within the glenohumeral joint. The limited joint volume effect is also compromised when the capsular boundaries of the joint are very compliant.
Glenoid labrum: a redundant fold of fibrous connective tissue which functions to increase articular surface area for the humeral head by deepening the glenoid fossa. Additionally the labrum cushions against impact of humeral head in forceful movements. Loosely attached superiorly, inferiorly firmly attached and relatively immobile.
Serves as an attachment for the glenohumeral ligaments and the long head biceps tendon to the glenoid. Anteriorly the labrum is continuous with the inferior glenohumeral ligament. The posterior-superior labrum is continuous with the long head tendon of the biceps. This site may be more vulnerable to injury and age-related degenerative changes because of a relatively poor blood supply as the labrum has a rich vascular supply to all but its superior aspect. Rotator Cuff: S.
Dynamic stabilization is achieved through a force couple with the deltoid. Acting alone, the deltoid produces a superior translator force on the humeral head.
Along with the rotator cuff a net translatory force is produced causing simultaneous depression and compression of the humeral head in the glenoid fossa. In addition to their stabilizing roles the infraspinatus and teres minor contribute to abduction by assisting external rotation of the humerus to prevent the greater tubercle from impacting the acromion. Long head of the biceps: proposed as a GH stabilizer functioning in humeral head depression and acceleration and deceleration of the arm.
The tendon is intra-articular but extra-synovial and may have a varied origin; the posterior glenoid labrum, the supraglenoid tubercle or both. Not a true joint because the only osseous link between the scapula and axial skeleton occurs at the clavicle. The ST joint is the least congruent joint in the body. The scapula moves through a gliding mechanism in which the concave anterior surface of the scapula moves on the convex posterolateral surface of the thoracic rib cage.
Smooth scapular gliding is assisted by bursa located at the superior and inferior angles and base of the scapular spine. Scapulo-humeral Rhythm — describes the movement of the scapula in relationship to the humerus.
As the head of the humerus moves, the scapula simultaneously seeks a position of stability in relation to the humerus to maintain the humeral head in optimal alignment within the glenoid fossa. Scapulo-humeral rhythm serves at least two purposes… 1. Preservation of the length-tension relationships of the glenohumeral muscles; the muscles do not shorten as much as they would without the scapula's upward rotation, and so they can sustain their force production through a larger portion of the range of motion.
If a stable osseous base does not exist for scapular musculature, stability is sacrificed. Muscles without a stable base of origin, muscles cannot develop appropriate or maximal concentric torque, resulting in decreased strength, muscular imbalance and compensatory functioning of other muscles. It prevents impingement between the humerus and the acromion.
Because of the difference in size between the glenoid fossa and the humeral head, subacromial impingement can occur unless relative movement between the humerus and scapula is limited.
Simultaneous movement of the humerus and scapula during shoulder elevation limits relative arthrokinematic movement between the two bones. This illustrates the importance of the scapula being able to maintain a position of stability prior to movement.
Lower trapezius activation is essential in maintaining the normal path of the instant center of scapular motion as the arm elevates. Examine overhead shoulder motion in ascending and descending phases. Abnormalities typically present in the descending phase during eccentric lowering.
When the scapula is unstable an actual reversal of muscle origin and insertion occurs. This reversal of muscle function pulls the scapula laterally because the more stable and distal end is the humerus rather than the proximal end of the scapula.
The patient is asked to retract both shoulders and sustain an isometric contraction for approximately 10 — 15 seconds or longer. An inability to maintain a sustained contraction along with pain or burning in the region of the rhomboids suggests paresis. Questionable if this technique is superior to a simple rhomboid MMT. A positive test is indicated by a decrease or abolishment of impingement symptoms suggesting paresis or inhibition of the serratus anterior and lower trapezius muscle s.
T2 superior angle 2. T4 scapular spine 3. The examiner stands beside the patient with the patient's arm hanging at his side. The examiner then gives an inferiorly directed traction to the shoulder pulls down on the elbow a positive test results when there is a noticeable inferior slide of the humeral head or where there is a marked increase in the space between the humeral head and the acromion.
Pain or apprehension is a positive test. With the patient supine, the examiner slowly abducts and externally rotates the patient's arm. The test is positive is the patient becomes apprehensive and resists muscle guards against further motion.
No translation should be expected in the normal shoulder because this test is performed in a position where the anterior ligaments are placed under tension. The examiner then internally rotates the patient's arm. An axial load is then applied to the patient's elbow. The test is positive if the patient becomes apprehensive and resists muscle guards against further motion. With the patient lying supine and a pillow resting under the scapula of the test side, the test extremity is axially loaded through the elbow and taken into horizontal adduction.
Reduce by removing axial load and taking test extremity into ABD and ER allowing an anterior roll and glide of the humeral head. As the arm is returned to the original position of degree abduction, a second jerk may be observed, that of the humeral head returning to the glenoid.
The examiner is standing at the head of the patient who is lying supine. The examiner places one hand under the posterior portion of the shoulder while the other holds the arm just proximal to the elbow. The test may also cause apprehension if anterior instability is present. The patient is either seated or standing. The test is positive if pain and weakness are present. The patient is then asked to slowly lower the test extremity to their side. The test is positive if the patient is unable to lower the arm slowly to their side in the same arc of movement or has severe pain when attempting to do so.
This is a highly provocative test because it requires eccentric contraction of the supraspinatus. The patient is seated or standing with the test arm behind their back; hand resting on their flank. The examiner stabilizes the patient's scapula while moving the resting arm away from the body.
Apprehension, muscle guarding or pain localized to the anterior shoulder may indicate rupture. While stabilizing the scapula, the examiner internally rotates the shoulder and then brings the shoulder into flexion. Pain reproduced over the coracoacromial arch indicates a positive test. The arm is then forced into internal rotation.
Pain over the coracoacromial arch would indicate a positive test for impingement. The patient's test extremity is moved into internal rotation and horizontal flexion a. This maneuver is thought to decrease the space between the head of the humerus and acromion process. The test is positive if the patient reports pain, indicating impingement of long head of the biceps or supraspinatus tendon. With the forearm supinated and elbow fully extended, the patient tries to flex the arm against resistance applied by the examiner.
The test is positive if the patient reports increased pain in the area of the bicipital groove. Pain is due to biceps tendon attempting to slide or move inside the bicipital groove while inflamed. Supination of the forearm against resistance produces pain in the biceps tendon in the area of the bicipital groove. The examiner then gently pulls inferiorly on the elbow putting traction on the shoulder joint and then attempts to externally rotate the shoulder. The free hand should palpate over the biceps groove feeling for a subluxation popping of the tendon from the groove.
Subluxation, pain, popping or clicking indicates a positive test. The patient is seated and clasps both hands on top of his or her head, supporting the weight of the upper limbs. The patient then alternately contracts and relaxes the biceps muscles. The test is positive if the examiner cannot palpate the long head of the biceps tendon of the affected arm during the contractions.
One of the examiner's hands is placed over the shoulder and the other hand behind the elbow. A force is then applied anteriorly and superiorly, and the patient is asked to push back against the force. The test is positive if pain is localized to the antero-superior aspect of the shoulder, if there is a pop or a click in that region, or if the maneuver reproduces that patient's symptoms.
The examiner grabs the patient's wrist and resists the patient's attempt to horizontally adduct and forward flex the shoulder. Pain, clicking or apprehension suggests a positive test. The test is considered positive if the patient reports pain, catching, or grinding in the shoulder suggesting impingement of the superior labrum between the humeral head and glenoid. A positive test is indicated by pain due to tearing of the connoid and trapezoid ligaments attaching to the clavicle.
MOI is typically a fall on an outstretched hand causing the acromion to be forcefully jammed up under the clavicle. The patient is then instructed to resist the examiner applying a uniform downward force directly below the olecranon process. The test is only considered to be positive if the patient reports alleviation of pain or symptoms with maximal supination or external rotation of the hand. Repetitive or excessive overhead manual labor?
Night pain? Think impingement! CKC activities help to reproduce or provide proprioceptive stimulation to joint mechanoreceptors GTO, mm spindle etc, which helps to reorganize and re-establish normal muscle firing patterns.
In addition CKC activities are protective in that they help to decrease muscular shear force on injured joints or healing tissues by promoting muscular co-contraction. A figure 8 clavicle collar may be used in acute stages to assist scapular elevation and retraction by helping to sensitize glenohumeral proprioceptors.
Posterior shoulder capsular stretching. To the left, motion is mainly between scapula and thoracic wall, which increases scapular slide because the scapula is not stabilized. The weight of the ball provides an eccentric stretch which is then converted to a concentric contraction. Progress to unilateral throwing of smaller weighted medicine balls or bilateral overhead ball toss against a spring trampoline.
J Am Acad Orthop Surg. Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med.
J Shoulder Elbow Surg ; Smith et. J Orthop Sports Phys Ther. Edward R. Levangie PK. Davis Publishing Co. Journal of Athletic Training. Cooper J. McFarland, E. Shoulder joint kinematics. Orthop Trans ; Performed and documented physical therapy treatments and care provided to patients using Re-Doc EHR system for patient documentation and billing. Utilized effective communication skills and promoted positive interpersonal interactions with patients, families and referring physicians.
Position required oversight, supervision and delegation skills for a team of two additional clinicians while managing a caseload of orthopedic, spine, sports-medicine, geriatric and worker's compensation patient populations. Became proficient in the use of Intergy and Athena EHR systems for electronic management of daily patient caseloads, workflow, documentation and billing.
Managed a hospital-based outpatient physical therapy clinic which provided rehabilitative services and supervised medical wellness. Duties included oversight of monthly budget reports, supply inventory and web-based employee payroll time sheet submission for a four employee support staff.
Assisted with the transition of clinic's physical re-location and consistently increased monthly revenue reaching highest monthly total in facility's history. Responsible for the daily operation and management of an outpatient private practice clinic in first two years of clinical practice.
Supervised a support staff consisting of two physical therapist assistants and an office receptionist. Successfully learned and implemented dictation based documentation for recording all patient related care. Assisted staff with patient ambulation and gait training, use of assistive devices, assisting with application of orthopedic devices and compiling home exercise and stretching programs.
Additional duties included general supervision of patients during exericse sessions, secretarial duties including desktop publishing, scheduling of patient caseloads, maintenance and cleaning of patient treatment areas and exercise equipment at multiple sites. Worked independently and under direct supervision of the Campus Networking Department Supervisor with the support, maintenance and operation of Misericordia University's campus network.
Provided phone or on site support to university students and staff for a campus of approximately 1, users. Position required a knowledge of networking basics including: Ethernet protocols, wire scoping, deployment and basic maintenance of network switches and cables, network troubleshooting related to internet, e-mail, database and printer access.
Provided help-desk technical support for physical, occupational, and speech therapy departments. Position required efficient troubleshooting skills, assessment of users' needs, and a background knowledge of the operating systems, software applications, and desktop systems currently used in the medical profession. Tasks performed included: data transfer, desktop publishing, dial-up internet access configurations, software installation, hardware deployment, and troubleshooting.
Provided user sensitive support, requiring recognition of problem situations and assessment of users' needs, while implementing a proactive approach to problem solving. Position required proficeint knowledge of numerous software applications as well as the ability to fix minor hardware and printing problems.
Excellent desktop publishing, HTML and code debugging skills which have positively contributed to improving paper and electronic based patient documentation in previous positions. Information technology, web design , development and networking.
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