shoulder Flashcards
Stability
GH
Joint
Static:
Articular surface shape, glenoid labrum,
capsule, GH ligaments
Dynamic:
Rotator cuffs, LH biceps, Rhomboids, Serratus Anterior, Deltoid
+ pec major and latissimus dorsi overall for shoulder
Epidemiology of Shoulder Complaints
– 3rd most common complaint
– Rotator cuff is the most prevalent; significant because of its effects on ADL’s
– Difficult to correctly diagnosis due to many structures involved and considering the C/S
as a potential cause of pain.
– Prevalence increases with age
– Women report more complaints
Common Sports for shoulder complaints
Repetitive overhead use of the shoulder - hyperabduction & ER
* swimming, volleyball, baseball, tennis players
History taking for shoulder complaint
– Age (important)
– Occupation / rec activity
– Pain location
– previous treatment
– patient medical Hx
Red flags for shoulder
Over 50 – increases risk of RC tears or other pathology
Night pain – tumour
Weight loss – cancer or autoimmune
Fever – systemic infection
Pain unrelated to activity or not relieved with rest — referred from visceral source
Hx of cancer – referral of pain and or metastasis
Cardiac risk factors – MI
Pleuritic pain – Pancoast tumour
Subacromial impingement
Creates a decrease of the space because of some other condition involved [umbrella term] covering multiple conditions such as:
- RC conditions, labral, GH instability, bursitis, anatomical involvement [osteophyte; mc AC joint], OA, scapular dyskinesia.
Labral Injury injury types
Traumatic:
- FOOSH,
- Inferior traction],
- dislocation/subluxation
Degenerative:
- Repetitive microtrauma
- overhead hyperabduction & ER
Clinical Presentation of Labral Injury
MOI: FOOS or direct impact onto shoulder
- Insideous or traumatic posterior shoulder pain
- Clicking and popping [painful]
- Decrease / loss internal rotation
- Overhead motion cause pain
- Decrease strength + endurance of RC and scap stabilisers
- Pain or inability to lie on
Clinical Assessment of Labral Injury
- Passive Compression Rotation Test
- Active Compression Test O’brian
- Crank test.
- Apprehension + relocation test
- Biceps load test I and II
- Resisted Supination ER Test
- Kim’s Test
- Speed’s Test
- Anterior Slide Test
- GH internal Deficit Test
Patho-antomy of Recurrent ASI
Lead to capsule-labral damage and osseous structures
Bank hart lesions most common in recurrent ASI
(labral avulsion - tensile force of anterior band – periosteum break}
Recurrent shoulder instability effects
Bone loss, cartilage loss and more soft tissue damage –>
Leading to: Chronic pain, functional impairment and ADL’s affected
Differentiate
type of shoulder instability
Anterior- discomfort abduction and ER throwing ball
Posterior: IR, adduction and forward elevation (pushing)
Multi- variety of positional symptoms, symptomatic with inferior translation
Physical Examination of Labral
Goals: After Hx, narrow differential diagnosis or confirm, Rule out pathology and obtain new information to influence management
- Strength testing should be done followed by,
- Special tests which should include apprehension testing, followed by,
- Ruling out concomitant pathology such as RCT tears** and labral,
- The assessment will then be concluded by assessing the overall shoulder laxity
General impression for paitent in diagnoses
A football player is likely to have anterior instability than a young underweight swimmer
Over 40 paitent consider rotator cuff tears
Over 60, consider tear, axillary n or brachial plexus injury
Assessing Laxity
The Gagey hyperabduction test. More than 1050 of GH abduction prior to initiation of scapulothoracic movement is considered abnormal
Orthopaedic Assessment for anterior labral
- Apprehension test + relocation
- Load and shift test (anterior & posterior)
- Surprise test
Orthopaedic Assessment for posterior labral
Posterior
1. Load and shift test (anterior & posterior)
2. Jerk test
3. Kim test
Orthopaedic Assessment for multidirectional labral
Multidirectional
1. Sulcus sign/test
Scapular stability test
- Scapulothoracic assistance test
- Scapulothoracic repositioning test
- Punch test
- Pectoralis Major/minor tightness test
Imaging for labral
Plain x-ray: Dislocation, Hill-Sachs lesion, bone loss, patho-anatomy, and or associated pathology
* CT
* MRI or MRA
ASD algorithm decesion operation
Non-Operative
* 10-13 years old (open physis)
* > 25-35 years, sedentary individual – without concomitant injury (fracture, RCT)
* Non-compliant with rehabilitation
* Stiff shoulder (has not regained full ROM)
Physician decision
* 14-35 years
* Presence of glenoid or humeral bone loss (% of loss)
* Athlete (contact vs non-contact) * In-season or off-season
* Instability severity Index Score*
Operative
* 14-35 years old competitive contact athlete – ISIS ≥ 4
* Significant glenoid or humeral bone loss (risk of imminent recurrent instability)
* Recurrent instability
* Humeral avulsion of the glenohumeral ligament
DDx for labral
Rotator cuff injury / or impingement
Labral injury
GH or AC arthritis
Suprascapular Instability
Frozen Shoulder
Referred Pain
Subacromial Pain Syndrome / Impingement
A painful condition of the upper extremity resulting from a structural narrowing of the subacromial space.
Shoulder impingement is now a broad term for non-traumatic, usually unilateral pathological processes involving different structures that induce shoulder pain and create a decrease in the subacromial space [impingement]
Subacromial Pain Syndrome / Impingement types + further classification
**External: **mechanical encroachment of soft tissue bursae or tendon between humeral head and acromial arch that occur 2nd to irritations within the anatomic space i.e inflammation
—> Pain mid range / pain arc 60-120 abduction
Internal: Encroachment of RC tendon between humeral head and glenoid rim often encountered in overhead throws or manual labour
> + anterior-superior
- postero-superior = RC tendon between humeral tuberosity and glenoid posterior superior rim
Further:
Primary: Structural narrowing of space
Secondary: Functional
Subacromial Pain Syndrome / Impingement: External/extrinsic clinical presentation
- Insidious onset no specific trauma
- Pain anterolateral of acromion and can radiate to upper arm
- Night pain common with sleeping position, overhead activity, and at rest because of inflammation
- Loss of motion [abduction and ER]
- Older patients AC OA contributing
- Painful arc pattern
Subacromial Pain Syndrome / Impingement
Orthopaedic tests
- Painful Arc
- Jobe Apprehension and Relocation
- Neer Impingement 4. Hawkins-Kennedy
- Resisted Supination External Rotation 6. Full – Empty can
- Resisted rotation Strength
Rotator Cuff Syndrome
Supraspinatus mc tendinopathy often causing impingment
Tears either traumatic or degerative
Rotator Cuff Syndrome Risk factors
Hx of trauma
Dominant Arm
Age
Rotator Cuff Syndrome Traumatic vs Atraumatic
Traumatic:
- Younger
- FOOS
- Forceful extended rotation on abducted arm
- Supraspinatus (mc), Infraspinatus,
- Subscapularis
Atraumatic:
- Older
- Non-traumatic
- Slow progression
- Likely started as small supraspinatus tear
- Fewer subscapular tears
Rotator Cuff Syndrome Risk Factors
- Overhead activity
- Pathology: diabetes, hypertension, high BMI and smoking
Rotator Cuff Syndrome Clinical presentation
- Middle aged older individual with non traumatic onset
- Pain in upper arm near deltoid insertion, worse with over head
- Weakness, loss of ROM and function
- Constant pain with painful arc (supraspinatus]
- Night pain lying on side
- May have pain putting on seatbelt
Rotator Cuff Syndrome - Tear and associated symptoms
- Supero-posterior tears show a loss of active ROM and weakness in external rotation
– +ve lag sign (infraspinatus) - Supero-anterior tears may display a loss of active ROM and weakness in internal rotation
– +ve lift-off sign (subscapularis)
Rotator Cuff Syndrome: Clinical evaluation
Supraspinatus: Empty/full can, drop arm, rent
Infraspinatus: ER, Patte, ER lag sign
Subscapularis: Lift off/ R, Lift off lag sign, Bear hug
Teres minor: Patte
Biceps: Speeds, Uppercut, palpation
Rotator Cuff Syndrome: Imaging
X-rays: adv diseases and changes at tuberosity, osteophytes etc.
MSK ultrasonography: RCT and bicipital pathology
MRI: Best assessment of pathology and differentiate intra from extra
Management decisions
Rotator Cuff Tendinopathy - Risk Factors
- Overhead repetitive movement
- Older age
- Anatomically factors i.e impingement
- Biomechanical Factors i.e deficits
- Pre-existing cervical degeneration
Rotator Cuff Tendinopathy - Pathophysiology
Intrinsic: tendon overload eccentric and degeneration + poor vascular supply to tendon
Extrinsic: compressive forces exerted on surrounding structures causing RC injury, and OA changes
Supraspinatus and deltoid both functions in abduction and flexion. Supraspinous primary stabiliser of the GH joint counteracting deltoid muscle action.
Rotator Cuff Tendinopathy - Clinical presentation
- Pain with overhead
- ADL painful
- May localise pain to lateral deltoid; often night pain, and lying on affected side
- Risk factors from hx
- Overhead athletes pain performing and weakness or decline in perfmance
Rotator Cuff Tendinopathy - Clinical Assessment
- Inspection of Muscle atrophy or scapula appearace and motion
- Neck exam
- Palpation
- ROM
- Strength testing
- Assessment algorithm
Rotator Cuff Tendinopathy - management
- Conservative strengthening, correcting imbalances and mobility, stabilising secondary movers, and correcting anything along kinematic chain
- Surgery if deficits interfer with ADL’s, persisting pain, worsening function, and persistent activity limitation
Rotator Cuff Tendinopathy Complications
>
Untreated leads to loss of motion, diminishing use, degeneration, adhesive capsulitis Patients with pre-existing RC disease increased chances of these all occurring
Bicipital Lesions / Tendinopathy
Most cases are secondary to RC injury, especially when impingement syndrome and instability is present. Therefore, bicipital pathology too often represents a diagnostic challenge as other pathologies must be rule-out.
Proposed
cause of tendinopathy of Bicipital Lesions / Tendinopathy
Primary inflammation of LHB in the bicipital groove [not common]
Secondary is most common, reported in high amount of people with tendinitis [RCT or SLAP lesion]
MOI commonly involves the transverse humeral ligament
Dislocation
May lead to acute rupture of tendon
Bicipital Lesions / Tendinopathy
Clinical presentation
- Anterior shoulder pain over biciptal groove, sometimes radiating down elbow
- Aggravated with shoulder flexion, forearm supination and elbow flexion
- Exacerabated by initiation of activty
- Described as fatigue
- Rest, ice, massage, stretching and heat can alleviate
- Night pain common
Bicipital Lesions / Tendinopathy
Long head vs Short head
Long Head:
- Older individuals from natural degeneratiion with hx of shoulder problems
- Younger individual tendon rupture following trauma
Short Head:
- Less common
- Same symptoms but minimal loss of strength
- Will result in 30-50% supination and 20% flexion strength so surgery is advocated
Differential Diagnosis: Bicipital Lesions / Tendinopathy
RCT, impingment, shoulder instability or labral pathology
Difficult as presents as anterior shoulder pain
Differential Diagnosis: Bicipital Lesions / Tendinopathy Management
Unless the patient has a complete tendon rupture or a high-grade partial tear at risk for complete rupture, treatment for proximal biceps tendon pathology begins with a conservative (non-operative) management algorithm for at least 6 to 12 weeks.
Surgical intervention is considered in patients who have failed conservative management algorithm and involves tenotomy or tenodesis.
Differential Diagnosis: Bicipital Lesions / Tendinopathy ManagementClinical evaluation
Long Head of Biceps
1. Speed’s Test
2. Uppercut Test
3. Bicipital Palpation
Distal Biceps Tendon
1. Squeeze Test
2. Hook Test
What population is Stiff shoulder most prevalent?
- Early menopause or post menopause, diabetes, and hypothyroidism
- Type 1 diabetes highest prevalent
Biomechanical
Pathophysiology of stiff/frozen shoulder?
- Insidious painful lasting over 3 months (average appox 30 months]
- Longer phase associated with longer recover
- Caused by fibrosis accompanied by gradual stiffness and a lot of restricted ROM
[ER and then abduction] - Thicken coracohumeral ligament [main limiter for ER]
- Loss of passive ROM = pathognomic sign
- Neck pain common
- Recovery is long but habitually
Adhesive capsulitis
Stiffness and pain, usually unilateral
Capsular pattern of loss ER, ABduction and IR [both active & passive]
Common over 50 years
Risk factors range from hormone conditions to MSK conditions
Physical examination of frozen/stiff shoulder
- No gold standard test
- Pure ROM must be assessed, ve+ finding 50% decrease or less than 30 compared to other side.
- ROM reduced in at least 2 planes by 25% (Abduction and fwd flexion]
- Shrug sign
- Lidocaine test for subacromial injection site
Management of frozen shoulder
Conservation:
* Restore to painless and function joint ROM
* Physical treatments are the first line of treatment combined with other treatment modalities for patients with early stages.
* Early mobilisation with physical therapy is recommended but studies have shown greater improvement with pendulum and gentle exercises
* At home exercises equally effective
* Pain management is key to allow for movement
Types of SC injury
- Type I: Mild pain with movement, may have swelling or slight tender to palpate
- Type II: Similar, but palpable subluxation of joint with manual stress testing [partial distrubt]
- Type III: Severe pain any movement, lying down increases. Patient holds arm
Managment of SC injury
Mild: ICE and analgesics, immobilise with sling, with gradual return
Moderate or subluxated: same, but immobilised with clavicle strap for a week, followed by sling immobilisation for addictional 4-6 weeks
Dislocations: close reduction
Describe the SC joint disc anatomy and function
The fibrocartilaginous disc is attached:
* Superiorly➙Clavicle
* Inferiorly➙manubrium
Disc orientation–
* Resists clavicle from being pushed medial over the top of the manubrium,
* allows shock absorption from the arm to the manubrium
AC Joint MOI
Direct: Falling on abducted arm which drives the acromion and clavicle inferior and medially injurying the capsule and ligaments.
Indirect: less common, falling on adducted arm driving the humeral head against the inferior acromion [low grade], disrupting the joint without affecting the CC ligaments.
AC Joint injury clinical presenation
- Pain over AC joint/superior aspect of shoulder
- Holding arm
- Hx of exacerbation sleeping that side
- Asymmetry with severe
- Pain at end range abduction [and with horizontal]
- Tenderness
- Tests provoke pain
DDx for AC joint
- Frozen Shoulder: pain decrease A and P ROM
- RCT: Assess muscle weakness
- Supraspinatus: local pain, tip of shoulder palpation painful
- Bicipital tendinopathy: anterior pain and with bicipital groove palpation
- AC pathology: deformity in bone, local palpation and compression tests
4 phases of conservative management for the AC joint
Phase 1: Pain management, early ROM, ice and short term immobilisation. Active-assisted ROM early. Scapular plane exercises I-E rotation and elevation and depression done to the point of pain.
Advance: 75% full of ROM, minimal pain or tenderness, muscle test grade 4
Phase 2: Full painless ROM and increase strength in isotonic arc. Active assisted motion, allowing full fwd flexion and I-E rotation performed at 90 abduction and with arm by patients side.
Advance: pain free ROM, no pain or tenderness, stretngth 75% compared to other
Phase 3/4: Increases strength of entire shoulder. With focus on isotonic dumbbell shoulder flexion, abduction and bench press.
Clinical evaluation of the AC joint
- AC joint palpation
- AC resisted Extension Test
- Horizontal adduction test
- Active Compression Test (O’Brien)
- Acromioclavicular Shear test
OA of AC joint
- Results from repetitive minor stresses, previous injury or clavicular fractures (Antero- inferior osteophytes)
- Can contribute to degenerative supraspinatus tear and impingement syndrome
SPADI
Shoulder pain and disability index
Higher the score for each scale, the higher the impairment to the shoulder function.
Questions on Pain and functional activities
MDC: 13
Upper Extremity Functional Index
Out of 80
MDC: 9 points
A lower score indicates that the person is reporting increased difficulty with the activities due to their upper limb condition.
