Lecture 16/17: Shoulder Clinical Conditions Flashcards
Thoracic spine & shoulder pain
- the thoracic spine will likely not radiate pain to the shoulder, but it can create shoulder dysfunction
- hypomobile thoracic extension will limit your ability to flex the shoulders
other musculoskeletal areas the patient was consider to be “shoulder pain”
- cervical spine
- elbow; however, typically we do not radiate pain proximally – meaning the elbow is likely not referring pain up to the shoulder, but what is happening at the elbow may influence the shoulder
Neurological that may be considered the shoulder
- HNP (herniated nucelous pulposus in thoracic or lumbar)
- TOS
- nueral dynamic dysfunction
Visceral that may be considered shoulder pain
- cardiac
- diaphragm
- gall bladder
- liver
- lung
- pancreas
- perforated duodenal ulcer
Neer’s Stage 1 category of painful shoulder syndrome
- Edema
- Hemorrhage
- pt usually < 25
Neer’s Stage 2 category of painful shoulder syndrome
-tendoniits/bursitis and fibrosis (patient usually 25-40)
Neer’s Stage 3 category of painful shoulder syndrome
- bone spurs
- tendonn rupture
- pt usually > 40
Neer’s stage based on
degree or stage of pathology of the rotator cuff
other systems based on impaired tissue
- supraspinatus tendonitis
- infraspinatus tendonitis
- bicipital tendonitis
- superior glenoid labrum and/or biceps instability
- subdeltoid (subacromial bursits)
- other musculotendinous strains (specific to type of injury or trauma)
anterior impaired tissue from
overuse with racket sports (pec minor, subscap, coracobrachialis, short head of biceps)
inferior impaired tissue from
motor vehicle trauma (long head of triceps, serratus anterior strain)
Mechanical disruption and direction of instability or subluxation
- multidirectional instability from lax capsule with or without impingement
- undirectional instability (anterior, posterior, or inferior) with or without impingement
- traumatic injury with tears of capsule and/or labrum
- insidious (atraumatic) onset from repetitive microtrauma
- inherent laxiity
Jobe’s classification based on
progressive microtraumaa
Jobe Group 1
Pure impingement
-usually in an older recreational athlete with partial undersurface rotator cuff tear and subacromial bursitis
Jobe Group 2
Impingement associated with labral and/or capsular injury, instability, and secondary impingement
Jobe Group 3
hyperelastic soft tissue resulting in anterior or multidirectional instability and impingement (usually attenuated but intact labrum, undersurface of rotator cuff tear)
Jobe Group 4
anterior instability without associated impingement
-result of trauma; results in partial or complete dislocation
Based on degree and frequency
instability - subluxation - dislocation
-acute, recurrent, fixed
Common pain impairments with rotator cuff disease and tendinopathies (all, some, or none may be present)
- pain at musculoteninous junction of the involved muscle with palpation, restricted muscle contraction, and when stretched
common postive signs for rotator cuff diseases and tendinopathies
- positive impingement sign (forced internal rotation at 90 of flexion) and painful arc at 90 arm elevation
common impaired posture impariments for rotator cuff disease and tendinopathies
- impaired posture: thoracic kyphosis, forward head, anterior tipped scapula with decreased thoracic mobility
common muscle imbalances for rotator cuff disease and tendinopathies
- hypomobile pec major and minor, levator scap, and internal GH rotators
- weak serratus anterior and GH joint rotators
common joint capsule impairments for rotator cuff and tendinopathies
-hypomobile posterior GH joint capsule
common spine mobility impairments for rotator cuff tear and tendinopathies
-hypomobile cervial or thoracic spine mobility especially with secondary impingement
common kinematic impairments for rotator cuff injuries and tendionopathies
- faulty kinematics during humeral elevation
- decreased posterior tipping of scapula (due to weak serratus anterior)
- scapular elevation and overuse of upper trap
- altered scapulohumeral rhythm during elevation or lowering of arm
with complete rotator cuff tear inability to
abduct the humerus against gravity
when acute:
pain referred to C5 C6 reference zones
Rotator cuff tear mechanism of injury
- end-stage impingement may cause tendon degeneration and progression to a complete tear.
- compromise of subacromial space, decreased vascular supply and spur formation - acute injury such as fall on an outstretched arm or abduction movement at high force and velocity may also cause a tear
rotator cuff population
- older than 40
* common exceptions*: traumatic injuries, pitchers
other condiitons accompanying a rotator cuff tear
- bicep tendon hypertrophy (may try to make up for the shoulder dysfunction)
- increased EMG of biceps (substiuting for rotator cuff muscles)
- biceps tendon rupture (most commonly seen in large/significant rotator cuff tears)
signs/symptoms of rotator cuff tears
- pain/loss of function (commonly reaching overhead, pain arc) - pain dependent on extensibility of tear
- grade 4: least painful, least amount of function present
- grade 1: most painful, most function present
- (+) AROM findings
- (+/-) PRO findings (tensile force when lengthened) - wouldn’t expect to be painful except at end-ranges
- (+) weakness or pain
- (+) provocation (special tests)
Rotator cuff procedures (least invasive – most invasive)
- arthoscopic approach
- mini-open (arthoscopically assisted) approach
- traditional open approach
Impingement syndrome
tendons of the rotator cuff and biceps and subacromial bursa are subject to inflammation as a result of direct blows, excessive tensile forces and/or repetitive microtrauma
Repetitive or sustained overhead activities frequently predispose the rotator cuff tendons to injury
mechanical (primary) impingement of subacromial structures occurs when
arm is lifted overhead, especially in abduction and flexion with the arm internally rotated (internal rotation has more possibility for impingement)
secondary impingement frequently involves
glenohumeral or functional scapular instability
population of primary impingement syndrome
- over 40
- overall wear and tear, related to aging process
population of secondary impingement syndrome
- associated with scapular instability
- < 35 yo
- usually athletic/occupational in nature; repetitive overhead movements
associated pathologies with impingement syndrome
bursitis (right under the acromion)
tendonitis
rotator cuff tears
degenerative changes (osteophyte formations)
signs and symptoms of impingement syndrome
- Anterior pain
- Difficulty with sleeping position
- (+) AROM findings
- (+/-) PROM findingd
- (+) weakness or pain
- (+) tenderness
- primary impingement usually grade 3
- (+) provocation (special tests)
Procedures for impingement syndrome
subacromial decompression (also known as anterior acromioplasy or decompression acromioplasty)
Shoulder instability definiiton
excessive displacement anteriorly or posteriorly of the humeral head in relationship to the glenoid
- created by lack of active or passive shoulder stabilizers leading to increaased likelihood of GH subluxation
population of shoulder instability
- younger male, athltic
- < 35
- repetitive overhead sport or occupation
types of GH instability
- anterior (common)
- posterior
- inferior
- multi-directional (anterior/inferior most common)
common progression of shoulder instability
microtrauma –> involuntary (sub-luxation) –> voluntary –> frank dislocation (fully dislocated)
signs and symptoms of shoulder instability
- anterior pain
- c/o of “clunk” “click” “pop”
- (+/-) AROM/PROM
- (-) weakness or pain
- (+) accessory motion tests
- (+) tenderness
surgeries for shoulder instability
- Bankhart repair
- Capsulorrhaphy
- Electrothermally assisted capsulorrhaphy
- posterior capsulorrhapy
- repair of SLAP lesion
Stability/Impingement relatonship
Overuse: repetitive, overhead activites stress tissues near physiologic limit –>
Microtrauma: if stress rate > repair state, tissue breakdown occurs (static stabilizers) –>
Instability: resultant instability - most often an ant/inf; may lead to asynch. coordination of scapular rotators and rotator cuff –>
Subluxation: cuff unable to stabilize humeral head alone, further muscle atrophy, progressive subluxation –>
Impingement: further cuff wear/tear –> superior head comp –> impingement –>
Rotator cuff tear: end-stage impingement
Adhesive capsulitis (frozen shoulder) characteristics
- occurs in 3-4 stages
1. gradual onset of pain (less than 3 months)
2. painful period (3-9 weeks - freezing)
3. stiff period (less painful, but has all the dysfunctions and can last 9-15 months) (frozen)
4. recovery period (15-24 months) (thawing)
-total duration of symptoms average 2+ years (self-limiting)
population for frozen shoulder
- age 40-70 (rare <40)
- females»_space; males
- 1/3 will develop contralateral problem in 5-7 years
primary frozen shoulder
- unknown etiology
- active and passive movements are painful
- markedly restricted in all directions (most in ER – following capsular pattern)
secondary frozen shoulder
- identical clinical syndrome occurring in association with a particular disorder or event
- (i.e., shoulder trauma, diabetes, thyroid disease, cardiac disease, nuerologic disease, pulmonary disease)
signs and symptoms of frozen shoulder (history of complaints)
- insidious onset or some trauma
- pain: becoming severe, present at rest (pain at rest is usually not normal, but for adhesive capsuliits it is) pain may be vague, generalized, may refer to forearm
- self-immobilization
- unable to lay on involved side
frozen shoulder tests and measures pattern
- dependent on stage
- all active and passive motions painful/restricted
- significant GH ER, moderate abducton limitations and some IR restriction (capsular pattern) (flexion is also limited)
- GH spasm end-feel, progressing to hard, capsular end-feel
- (+) impingement test
- hypomobile accessory motion
- ?? (+) resisted tests
- dependent on person and patient position
- may get a (+) resisted test even though you’re not suppose to becaause its a capsular problem
Shoulder girdle treatment considerations
- acute, subacute, chronic
- mobility vs stability (priority to whichever one is most limited)
- GH, scapula, trunk
- funcitonal
shoulder flexion glides
posterior and inferior
shoulder lateral rotation glide
anterior glide
shoulder abduciton glide
inferior glide
shoulder medial rotation glide
posterior glide
Retraction SC glide
posterior glide
Depression SC glide
superior glide
AC Protraction glide
anterior glide
AC retraction glide
posterior glide
