shoulder 2 Flashcards
ant. instability/sublux
- Displacement of humeral head – no longer in centre > o Loss of joint integrity due to failure of restraints
- could be due to laxity
- Anterior most common
Affects structures that usually stop anterior subluxation from occurring. Gradual breakdown of active and passive restraints.
MOI:
overhead athletes w/ capsular laxity
o Post- traumatic- excessive abduction and/or external rotation
o Atraumatic - Acute traumatic episode in a lax shoulder
o Congenital- shape of glenoid, musculature
o Overuse - Repetitive load or action (throwers, swimmers, overhead athletes) causes microtrauma due to increased humeral head translation
♣ Motor control concerns – consider force couples that act to keep the HOH well positioned in the glenoid.
Symptoms
o Recurrent dislocation or subluxation
o Anterior shoulder pain due to impingement of the RC tendons associated with recurrent anterior translation of the HOH > can result in RC tendinopathy
♣ catching of a labral detachment
o Feeling that the shoulder is popping out +/- apprehension
♣ Starts with activities in ER and ABD but then more frequent and with simple activities such as rolling over in bed
o Transient numbness and weakness in the arm (‘dead arm syndrome’)
o Intermittent impingement, catching, clicking , clunking (due to labral involvement and translation of HOH)
Ant Ax
• Observation
o Prominent HOH anteriorly
o Loss of contour of the shoulder
o Winging +/- protraction of the scapula
o Supports arm away from their body, leans towards affected side
o Overactivity of deltoid (in an acute dislocation)
o If they have had repeated dislocations or not treated changes in muscle bulk
• Palpation
o Tenderness on anterior shoulder > related to changes of anterior structures
o Possibly tender at posterior shoulder if significant traction has occurred
• Movement and muscle exam
o Normal or hypermobile active and passive ROM
o Increased P-A glide +/- decreased A-P glide (remember to glide on an angle)
♣ Acute: decreased A-P
♣ Chronic: increased A-P
♣ Feel for end feel and resistance
o Weakness +/- altered control of the rotator cuff muscles
♣ Esp. supraspinatus as a tear to this muscle often occurs with this pathology in older adults.
o Inability of subscapularis to centre or control the position of the HOH**
• Special tests
o Positive for:
♣ Apprehension relocation test (patient will stop you from going any further)
♣ Load and shift test > reproduce painful catching; tests for laxity
♣ Sulcus sign
♣ Anterior capsule length test for laxity (decrease in resistance to stretch)
• = anterior drawer. Reproduce painful catching.
♣ Labral integrity
Other assessment required • X-ray or CT scan o Bankhart lesion o Hills-sacks lesion • MRI o Labral injuries o Capsule, ligament or tendon injuries
Ant. instability Mx
Gold standard
• Arthroscopic Bankart lesion repair
• Other mechanical problems (Hill-Sacks) also repaired at this time
Management depends on severity
Aim:
1. increase local shoulder stability and positioning by retaining supporting muscles
-1. Upper trapezius and serratus anterior
2. UT, SA and lower trapezius
3. Middle trapezius and serratus anterior
• Subscapularis
o Increase its activity in internal rotation (supported by evidence
- correct abnormal shoulder movement esp. during abduction and flx.
- dec. deltoid activity and inc. rotator cuff activation in these positions to depress HH
1st = local conscious muscle control
- Go into strengthening exercises – closed (strength, co-contraction) > open
- Increase load and mvmt
- Progress to functional positions to recuit kinetic chain
- maintain general fitness
IMPINGEMENT INTERNAL VS EXTERNAL
can be external = subacromial impingement
Mechanical encroachment of soft tissues in the subacromial space between the humeral head and acromial arch (e.g. bursa, rotator cuff tendons)
§ Pain during mid-range of movement – painful arc during abduction
§ Pain typically on lateral arm (near deltoid insertion)
§ Night pain (lying on affected side)
- Can be secondary or primary
or internal = internal posterosuperiod glenoid impingement
Encroachment of rotator cuff tendons (esp. supraspinatus & infraspinatus) between greater tubercle of humerus and posterosuperior rim of glenoid
Esp. when humeral shaft extends beyond the plane of the body of the scapula (e.g.
when scapula fails to retract)
Clinical features:
§ Pain during late cocking position of throwing (max ER, horizontal abduction +/- elevation [depending on sport])
- Generally secondary causes
IMPINGEMENT PRIMARY VS SECONDARY
primary: Pain caused by structural narrowing of the subacromial space and bony structural abnormalities
e.g. GENERAL FROM ROTATOR CUFF PATHOLOGY
AND acromioclavicular arthropathy, type II or III acromion, subacromial bone spurs, swelling of soft tissues in subacromial space (bursa, RC tendons)
secondary: No structural obstructions. Pain caused by functional problems in specific positions
e.g. rotator cuff weakness, instability, scapular dyskinesis, GIRD, SLAP
Example: RC dysfunction may result in impaired ability to prevent superior
humeral head movement during elevation - impingement
Can be internal (glenohumeral joint) or external (subacromial space)
SUBACROMIAL IMPINGEMENT
• Impingement (irritation) of the rotator cuff tendons as they pass through the subacromial space
• A sign/ symptom, NOT a diagnosis! a result of many factors
o Primary external: structural – anything that leads to the narrowing of the space
♣ shape of the glenoid or HOH
♣ beaked or curved acromion (bony projection into subacromial space)
♣ AC joint OA; sclerosis of the greater tubercle; subchondral cysts
o Secondary external: motor control
♣ Control around the shoulder girdle resulting in the anterior and inferior movement of the scapula
♣ Shortening of pectoralis minor causing a protracted scapula
♣ Anything that allows the HOH to elevate e.g. weakness of the rotator cuff, muscle imbalance, subscapularis (important for positioning of HOH)
Internal: repetitive microtrauma
stages of tendon damage in impingement
I: swelling and haemorrhage due to mechanical irritation (AGE: young, active people – reversible)
II: fibrosis and tendinosis due to repeated episodes of mechanical compression. Thickening and fibrosis of subacromial bursa. AGE: 25-40 years.
III: bone spurs and tendon rupture due to ongoing mechanical irritation and compression. Architecture of the acromion is often involved.
Patient history
- subacromial impingement
♣ MOI
o Congenital (shape of acromion- flat, curved or hooked)
o Bony growth
o Overuse (repetitive load or action > overhead movement in ER and ABD) = Causes the greater tubercle to impact under the acromion
o Abnormal movement patterns > mechanically compressing tissues
o Motor control
o Decreased passive stability (superior translation of HOH)
o Posterior capsule shortening- causes anterior position of HOH and pushed the greater tubercle into the under-surface of the acromion when shoulder is elevated.
♣ Complaints and functional limitations
o Pain inferior to the acromion and posterior shoulder
o Pinching in elevation
o Problems and pain associated with overhead activities throwing, freestyle
- subacromial impingement ax
Physical examination ♣ Observation o Protracted +/- winging of scapula o Inferiorly rotated scapula o Anterior humeral head o Protracted shoulders o Thoracic kyphosis - hard to flex spine and elevate shoulder. Postural fault.
§ Pain during mid-range of movement – painful arc during abduction
§ Pain typically on lateral arm (near deltoid insertion)
§ Night pain (lying on affected side)
♣ Movement examination
o Painful arc of movement between 60 - 120 degrees of shoulder abduction
o Decreased strength, endurance and motor control of the rotator cuff muscles
o Poor neuromuscular control of the scapula
- Altered scapulohumeral rhythm/scapuladyskinesia
o poor control/centring of the HOH
- superior movement of the humeral head with deltoid contraction
- inability to centre the humeral head in the glenoid
- decreased A-P glide +/- increased P-A glide of the GHJ
- dependent on if anterior instability is a part of the problem
• shortening of the posterior capsule
o downward rotation scapula
♣ special tests
o positive for:
♣ impingement tests (Neer’s and Hawkins Kennedy)
♣ posterior capsule tightness
♣ anterior capsule laxity +/- instability (load and shift, apprehension)
♣ empty can and Gerber’s lift off
Other assessment required?
♣ MRI to confirm rotator cuff tendinopathy or partial thickness tear
♣ Referred to surgery if damage to rotator cuff is in avascular zone?
subacromial impingement mx
Treatment – no need to mobilise joints if normal joint glides in P/E (?)
1. Improve scapulohumeral rhythm
• If the scapula doesn’t move correctly, the glenoid won’t make a good position with the head of the humerus and this may cause impingement.
• HOW**
• PNF: anterior depression and posterior elevation etc
- Retain supporting muscles to improve positioning and stability
• Rotator cuff
o Strengthen rotator cuff muscles - Should be able to internal and externally rotate the rotator cuff without scapular movement
- Start in neutral rotation with low load and a short arc (ROM) of movement of isometric
- Progressions: isometric to isotonic, arc of movement,
Load, movement speed, shoulder position and movement
♣ Monitor eccentric control
- Improve rotator cuff activation to depress the humeral head during deltoid activation in abduction
- Improve scapular stability during rotator cuff contraction
* subscab
subacromial impingement mx
- Improve scapular stability at rest and scapula upwards rotation during abduction
• Ensure simultaneous ER with shoulder ABD
o If not, the humeral head will impinge in the glenoid - Improve centring of the HOH
• Train awareness
o Instruction, visual and tactile input, manual correction, manual facilitation/inhibition, taping
• Stretch restricted tissues
o Posterior capsule- internal rotation deficit
o Anterior capsule – external rotation deficit (swimmers stretch)
• Train activation and strength of subscapularis
o Use contraction, not activation ?? - Train the sensorimotor system- proprioception and reaction time
• This aids with awareness
• Example exercise is pictured - Strengthen weak muscles
• Serratus anterior
o Elbow to the sky- palpate to ensure that It is an individual contraction
• Supraspinatus
Isometric contraction at 15 degrees into a wall
subacromial impingement mx
- improve scapulohumeral ryhtym
- keep progressing supporting muscles to improve positioning and stability
- Improve scapular stability at rest and scapula upwards rotation during abduction
- Improve centring of the HOH
- Train the sensorimotor system- proprioception and reaction time
- Strengthen weak muscles
