Shoulder complex soft tissue conditions Flashcards
common pathologies
AC Joint Injury
Frozen Shoulder Contraction Syndrome
Shoulder Instability
which joint is less stable acromioclavicular joint or shoulder joint
AC joint
More prone to injury and degenerative changes
types of AC joint injuries
levels I-VI
What levels of AC require surgery
IV-VI
Identify level 1 AC injury
Local pain, swelling and tenderness over the joint
No obvious deformity
how would level 1 AC injury be tested
Pain with passive shoulder movements especially horizontal flexion- Scarf test
treatment for level 1 AC injury
Initial rest -from aggravating activities, use of analgesics, ice. Start movement after a few days
how would level II AC injury be identified
Slight step deformity
Increased pain compared to type 1
Limitation of movement –abduction of the arm >90°.
how would level II AC injury be tested
Pain with Scarf Test
treatment for level 1 AC injury
Broad-arm sling (elbow supported) for approx 1-2 weeks
Analgesics for pain relief
when will exercise commence after level II AC injury
Commence gentle exercise after approx 2 weeks
how would level III AC injury be identified
Obvious step deformity
treatment for level III AC injury
Treatment:
Sling for approx 2-3 weeks.
Analgesics
Physio post immobilisation
how would level IV-VI AC injury be identified
Complete rupture of all ligament complexes
Much rarer
Require surgery
observations made during examination to detect an AC joint injury
step deformity
ROM for AC joint injury
Variable – may be limited by pain
Depending on grade
Flexion/Abduction most limited at End of Range (EOR)
palpation for AC joint injury
Local tenderness over ACJ
early stage conservative management for AC injury
Mx depends on severity
Based on general principles of ligament sprains
POLICE
in the early stage of conservative management of AC injury - how long should the patient rest?
Approx 3-4 weeks, but depends on grade
what type of exercises should be prescribed to patients in the later stage of the conservative management of an AC injury
Start with gentle active and passive ROM exercises
Strengthening: start with isometric and progress depending on grade and pain
Joint mobs for pain and stiffness at later stage
later stage rest for conservative management of AC injury
No return to sport/heavy activity until full pain-free ROM, no tenderness and full strength
surgery for level IV-VI AC injury
Insertion of pins, screws
Immobilised for a few weeks post surgery
Following D/C of sling, referral to Physiotherapy
Post-Op Protocol as per Surgeon
frozen shoulder contraction syndrome
Condition of unknown aetiology distinguished by painful restriction of shoulder movements, passive and active
how is frozen shoulder contraction syndrome characterised
by prominent reduction in gleno-humeral ROM
Other terminology ‘Adhesive Capsulitis’
what age group is affected by frozen shoulder contraction syndrome
40-60 yr olds
mainly women
stage I pathology synovitis
Vascular inflammatory synovitis
stage II pathology synovitis
Predominance of red synovium with early adhesion formation
stage III pathology synovitis
Pink synovium and more pronounced adhesion formation
stage IV pathology synovitis
Synovitis disappears, marked white capsular restrictions
how is synovitis characterisied
pain - followed by stiffness
purpose of X ray investigations in synovitis
Outrule other pathologies e.g.
Fracture, avascular necrosis
normal or minimal age-related incidental degenerative changes
clinical stages
freezing
frozen
thawing
freezing clinical stages time length
10-36 weeks – most severe pain with gradual decrease in articular movement.
frozen clinical stages time length
4-12 months – pain decrease with no appreciable increase in movement.
thawing clinical stages time length
12 months to years – gradual return of ROM
symptoms of freezing stage
Most Painful phase
Pain > stiffness
Pain at night, cannot lie on that side
Pain can be constant, can extend below elbow
symptoms of frozen stage
Increasing stiffness but decreasing pain
Capsular pattern LAM: most limitation of
Lateral rotation > Abduction > Medial rotation
more or less muscle weakness
capsular pattern meaning
predictable sequence of loss of ROM
how can frozen stage be palpated
harder end feel to movement
symptoms of thawing phase
Recovery Phase
Gradual return of movement- may not return to 100%
Less pain, usually at the end of range
Between 20-50% can have residual pain and stiffness after this time
what does treatment of pathology depend on
depends on stage
Pain dominant
Vs Stiffness dominant
type of medication for pain predominant freezing stage
Corticosteroid Injection
Evidence of short-term benefit (Wang et al, 2017)
Oral analgesics or NSAIDs
physiotherapy for pain predominant freezing stage
Gentle assist active movement
Joint Mobilisations (Gr II for pain)
Acupuncture-low evidence (Ben-Arie et al, 2020)
pros and cons of steroid injections
brings pain down short term but allows patient to do physiotherapy
physiotherapy for stiffness predominant injury
ROM exercise Passive stretching Joint mobilisations (Gr III for stiffness) AP/PA/inf glides AP good to increase LR
cons of using manipulation under anaesthetic
poor evidence
Risk of haemarthrosis
Requires physio afterwards
arthrographic hydrodistension
for stiffness predominant
(injection of NaCl into GH joint to distend the contracted capsule)
Requires physio afterwards
prognosis for frozen shoulder AC injury
Average duration of symptoms =30 months (1-3.5 years)
Although self-limiting
About 10% of patients will have residual shoulder stiffness and disability
Up to 4 years later, 41% reported some ongoing symptoms
3 types of shoulder instability
traumatic dislocation - torn loose
interior instability - worn loose
multidirectional instability - born loose
shoulder instability
Pathologic increase in translatory movement that interferes with joint function and causes pain
factors contributing to shoulder stability
anatomy and dynamic restraints
anatomy restraints
Glenoid labrum
Ligaments
Intra-articular pressure
dynamic restraints
Rotator cuff, Long Head of Biceps (LHB)
aetiology of traumatic dislocation
Force/fall on externally rotated and abducted arm
In the young (<35) can be related to sport e.g. rugby, soccer, gymnastics.
In the older (>35) usually related to fall
associated lesions of trauamtic dislocation
Tear of capsule
Damage to attachment of the labrum to the anterior glenoid (Bankhart lesion)
Compression fracture of the posterior humeral head (Hills-Sach Lesion)
complications of acute dislocation
Axillary nerve injury
Brachial plexus injury
Vascular injury (rare)
Rotator cuff injury
Fracture of the greater tuberosity/ humeral head/ glenoid
Recurrent dislocation / instability (long-term)
clinical features of shoulder dislocation
Loss of deltoid contour Hollow under the acromion Patient holds arm adducted and supported Patient often reports that his shoulder is “out” Arm looks longer Severe pain
conservative management of shoulder dislocation
Sling and immobilisation 3-6 weeks depending on age of person.
In sling: ROM elbow/scapular movement. Advise re washing and dressing
Pain is usually not a feature once reduced
Progressive strengthening an ROM on r/o sling
Sports Specific rehab
conservative treatment on removal of sling after dislocation
Assisted active ROM
Progress to Active ROM
Avoid external rotation initially…why?
Ensure normal scapulohumeral rhythm re-established
Focus on Rotator cuff, LHB, scapular stabilisers, Deltoid strength
Combination of open and closed kinetic chain exercise
Functional retraining e.g. Sports-specific
Proprioception training
closed chain upper limb
upper limb is in contact of object or surface limiting extension of muscle (idk)
recurrent dislocation caused by
bankart lesion
symptoms of anterior instability worn loose
Pain with throwing- dependent on the type of instability-History of repetitive use, overhead sports
Deep pain in shoulder
Associated click/clunk with movement
Sharp catches of pain through range.
worn loose
overstretch capsule - repeated force and overuse
typical causes of anterior instability - worn loosed
Bankart lesion
Internal Impingement
SLAP lesion
GIRD
signs of anterior instability
Excessive ROM with end- range pain (ER/ABD)
May have midrange pain if associated impingement e.g. painful arc
Isometrics in midrange are often pain-free and full strength (unless associated impingement)
BUT Weak in EOR / instability position (ER+ Abd)
stability tests - -hard to evaluate w/ muscle guarding
apprehension and relocation
put patient supine
abduction/external rotation to point of pain an apprehension
can provoke instability - be careful
tests for shoulder dislocation
load and shift test ant-post movement
sulcus sign - inferior movement
SLAP
Superior Labral Ant to Post where LHB attached.
Diff Dx: LHB lesion, Bankart lesion
Labral tear
subjective feature of labral tears
Assoc with throwing sports, carrying/dropping heavy object.
Pain located in posterior shoulder
Aggravated by overhead and HBB
+/- popping, grinding, catching sensation
what would be detected in physical exam of shoulder dislocation
Pain with LHB tests
Specific SLAP lesion tests: O’Brien’s test
May have positive Apprehension test
Confirmed with MRA (better than MRI) and Arthroscopy
internal impingement
Impingement of RC against posterior-superior surface of glenoid
aetiology of internal impingement
Repetitive trauma
Secondary to labral injury
GIRD
Glenohumeral Internal Rotation Deficit (GIRD)
