9.1 Shoulder Conditions

Question 1

What is the definition of impingement syndrome?

Answer 1

Impingement syndrome is a general term describing shoulder pain, typically diagnosed following a positive mid range painful arc as well as various other impingement special tests. Typically referring to pinching on structures in the subacromial space during humeral elevation.

Question 2

What structures in the subacromial space can get pinched with impingement syndrome?

Answer 2

• Supraspinatus tendon
• Subacromial bursa
• Biceps long head tendon

Question 3

At what range in the painful arc with their GH doing joint pain? Acromioclavicular joint pain?

Answer 3

• GH joint: in 45° to 120°
• AC joint: in 170° to 180°

Question 4

What are some intrinsic factors that cause primary impingement at the subacromial/suprahumeral space?

Answer 4

• Vascular changes in rotator cuff tendons (due to secondary disease process, age)
• Structural variation in the acromion (flat vs hooked)
• Trophic changes to the humeral head, AC joint, coracoacromial arch (fibrosis and thickening of coracoacromial ligament)
• Post-traumatic/postsurgical scarring

Question 5

What are some extrinsic factors resulting in decreased suprahumeral space and repetitive trauma to soft tissue during humeral elevation?

Answer 5

• Posterior capsule tightness causes anterosuperior translation of humeral head
• Weak external rotator/short internal rotators: restricts ability for humerus to externally rotate during abduction and restricts ability for greater tubercle to clear acromion (anterior cuff dominates posterior cuff)
• Deltoid overpowers rotator cuff: net superior translation of humeral head during abduction
• Poor scapular stability and muscular imbalances: if scapula is not stable, it doesn’t allow for optimal length-tension relationship of rotator cuff muscles
• Hyperkyphosis: places scapula into position rotation, protraction and anterior tipping. Also places humerus into a position of internal rotation
• Rotator cuff (and biceps LH) overuse and fatigue: if these muscles are fatigued from overuse, they no longer provide the dynamic stabilizing and compressive forces required for normal joint mechanics
• Tendonopathy: inflammation (edema) decreases subacromial space with tendinitis, thickening/fibrosis decreases subacromial space with tendinosis
  
  • Supraspinatus: pain on palpation of tendon inferior to anterior of chromium, painful GH arc, positive impingement test
  • Infraspinatus: pain on palpation of tendon inferior to posterior corner externally of acromion when patient externally rotates and horizontally adducts, painful GH arc with abduction and flexion
  • Biceps long head: pain on palpation of tendon in bicipital groove, positive speeds test
• Chronic inflammation and tendon overload can also stimulate the formation of osteophytes in the joint, which can further damage the surrounding musculature

Question 6

What is difficult to differentiate from supraspinatus tendinitis because of the anatomical proximity?

Answer 6

Subacromial bursitis

Question 7

Where might subacromial bursitis refer pain to?

Answer 7

To the deltoid insertion

Question 8

How might subacromial bursitis present?

Answer 8

• Acute burning or sharp pain
• Painful “catch” when lowering arm from full abduction
• Pain on release of speeds test (Isometric shoulder flexion)
• May refer pain to deltoid insertion

Question 9

In the cases of rotator cuff tears, either partial or full thickness, what should be emphasized during treatment?

Answer 9

Treatment needs to emphasize optimal joint/muscular mechanics. This includes normalizing posture, muscle imbalances (Length, strength, endurance) and tissue health/extensibility.

Question 10

What is secondary impingement?

Answer 10

Due to instability (multi or unidirectional) impingement is the secondary result

Question 11

What are some causes of secondary impingement?

Answer 11

• Lax connective tissue, greater translation of humeral head in one or multiple directions
• Labral or rotator cuff tears
• Dislocation

Question 12

What’s the aka for primary frozen shoulder?

Answer 12

Adhesive capsulitis

Question 13

What is the capsular pattern for shoulder?

Answer 13

External rotation, abduction, internal rotation, flexion

Question 14

Where are some causes of secondary frozen shoulder?

Answer 14

• Another issue presents in which there is a period of pain and/or restricted motion that results in chronic inflammation and capsular adhesion
• OA/RA
• Immobilization (fracture, dislocation, surgery)
• Trauma

Question 15

What’s the onset, age of onset, and cause of primary frozen shoulder?

Answer 15

• insidious onset
• usually between ages 40-60
• more prevalent in women
• unknown cause
• some studies have linked chronic inflammation in musculotendinous or synovial tissue (rotator cuff, biceps tendon, joint capsule) to the development of primary frozen shoulder

Question 16

What happens in stage one primary frozen shoulder?

Answer 16

• Gradual onset of pain that is aggravated by movement present at night
• Loss of external rotation motion with intact rotator cuff strength is common (capsular restriction)
• Duration is usually less than three months

Question 17

What happens in stage two “freezing” primary frozen shoulder?

Answer 17

• Persistent and intense pain even at rest
• GH motion is limited in all directions and cannot be fully restored within an intra-articular injection (anti-inflammatory)
• Duration is usually 3 to 9 months

Question 18

What happens in stage three “frozen” primary frozen shoulder?

Answer 18

• Pain only with movement
• Significant adhesions, limited GH motions with substitute motions in the scapula
• Atrophy of the deltoid, rotator cuff, biceps, triceps may be noted
• Duration is usually 9 to 15 months

Question 19

What happens in stage four “thawing” primary frozen shoulder?

Answer 19

• Minimal pain
• No synovitis
• Significant capsular restrictions from adhesions
• Motion may gradually improve during this stage, though some patients never regain normal ROM
• Duration is usually 15 to 24 months

Question 20

Which stages of frozen shoulder are treated as acute, subacute and chronic?

Answer 20

• Stages 1 and 2: tx as acute
• Stage 3: subacute
• Stage 4: chronic

Question 21

What’s a bankart lesion?

Answer 21

Detachment of the interior capsule and glenoid labrum. May also include the biceps long head tendon.

Question 22

What’s a SLAP lesion?

Answer 22

Tear of the superior labor, anterior to posterior. May also include the biceps long head tendon.

• This may occur through traumatic mechanism (fall on an outstretched arm or bracing steering wheel during MVA)
• Or through repetitive overhead motions (Baseball throw, volleyball spike). Biceps LH tendon attached to labrum superiorly. Studies suggest that loaded maximum external rotation and abduction creates a ‘peel back’ mechanism –> a twist through the biceps LH tendon that pulls on the superior labrum

Question 23

What’s a reverse bankart lesion?

Answer 23

tearing of the posteroinferior labrum and often the posterior band of the inferior GH ligament

• Typically occurs with posterior dislocation
• Can also have a combination of the three lesions, which is called a 270° lesion

Question 24

What’s a Hill-Sachs lesion?

Answer 24

• Compression fracture of the posterior aspect of the humeral head
• Occurs during anterior dislocation as the posterior humeral head contacts the anterior rim of the glenoid
• Usually accompanies the Bankart labrum lesion
• May or or may not be repaired surgically depending on the size
• IndiCongratulate shoulder instability

* can also have a reverse Hill-Sachs lesion during a posterior dislocation that typically accompanies a Reverse Bankart labrum lesion

Question 25

90% of dislocations happen in this direction (any why)

Answer 25

• anterior
• This is because of scapular position (30° anterior to the frontal plane) and the relative anterior resting position of the humeral head

Question 26

What’s the rehabilitation schedule after a dislocation?

Answer 26

• AAROM (3 wks post), limiting external rotation
• pendulum exercise, scapular retractions (4-6 wks post)
• AROM limiting external rotation, isometric rotator cuff and scapular retraining (7-8 wks post)
• AROM with end range stretch, isotonics (9-12 wks post)
• Non-contact sports with no overhead activity (3 mos post)
• contact sports with overhead activity (4 mos post)

Question 27

What’s a shoulder separation?

Answer 27

• injury involving the AC joint
• ranges from a sprain of AC lig to a full separation of clavicle from acromion

Question 28

What are the grades of shoulder separation?

Answer 28

• gr 1: sprain to AC lig, no separation
• gr 2: rupture of AC lig, sprain to coracoclavicular lig, slight displacement of clavicle
• gr 3: rupture of AC and CC ligs, full separation of clavicle from acromion

Question 29

What are degrees of SC joint injury?

Answer 29

(uncommon, SC joint is very stable with strong ligamentous support; typically clavicle will fracture prior to SC dislocation)

• 1st degree: sprain of SC lig
• 2nd degree: complete tear of SC lig, partial tear (at most) of CC lig, clavicle subluxes from manubrium
• 3rd degree: complete rupture of SC, CC and dislocation of clavicle from manubrium

Question 30

What are treatment options for shoulder separation?

Answer 30

• NSAIDs
• ice
• immobilization 1-3 wks
• taping for stability
• therapeutic exercise
• possible surgery for gr 3 separation

Question 31

What are treatment options for SC joint injury?

Answer 31

• NSAIDs
• Ice
• Immobilization
• Possible stabilization surgery (uncommon). Typically a tendon graft to stabilize joint, usually with the palmaris longus tendon.