Shoulder conditions (subacromial pain syndrome + frozen shoulder) Flashcards
What is a symptom of SAPS
Pain is commonly experienced at the superolateral side of the shoulder.
Pain and decreased shoulder movement + function, are usually experienced during shoulder elevation and external rotation.
Pain when lying on shoulder + feel weak and painful
Pain can flare and settle then flare in a cycle.
What does SAPS originate from?
It is thought to originate from structures in the subacromial space - rotator cuff, long head of biceps and the subacromial bursa.
Usually gradually and insidiously, occasionally overload or incident can trigger the condition.
Why does SAPS pain occur during elevation + abduction?
Due to contraction of a pathological and painful rotator cuff or because painful subacromial structures are being compressed against the undersurface of the acromion.
Extrinsic theories of SAPS?
Symptoms thought to be due to abrasion of rotator cuff tendons with undersurface of anterior acromion + coracoacromial ligaments. causing damage to soft tissues of subacromial space.
Predisposed to SA + rotator cuff tendinopathy if they had:
- specific acromial shape
- A/C joint OA
- A/C joint bone spur
Intrinsic theories of SAPS?
Pathology within rotator cuff tendons.
- Acute cuff overload
- Chronic overload/degeneration
Why does pain occur during contraction or compression of tendons?
- irritation of free nerve endings in a pathological tendon
- related to inflammation at certain stages of pathology
Why does cuff damage cause instability
- pathological + weakened rotator cuff - harder to maintain stability of humeral head
- excessive translation of the head of humerus on the glenoid
- damage to supraspinatus tendon will compromise its function as a humoral head depressor
- thus, leading to superior migration of the head of humerus + the cuff into the coracoacromial arch
Different types of rotator cuff tears?
Partial thickness tear
- supraspinatus commonly affected
- more common on articular side as fibres weaker + fail more quickly under tensile loads
Full thickness + massive cuff tears
- through inferior to superior surface
- greater than 5cm
- can extend to teres minor or subscapularis region
Other factors predisposing SAPS?
- poor posture
- altered scapular control (dyskinesis) - alters length-tension relationships on RC muscles
- glenohumoral instability - causes laxity of capsule
what is sensitivity in special tests?
how good a test is at diagnosing a condition when condition is there
what is specificity in special tests?
how good a test is at ruling out a condition when a condition is not present
useful clinical tests for SAPS?
- painful arc → useful as sensitive stuructures are compressed under the acrominum at 60-120 degrees.
tests for cuff tears?
integrity tests - e.g. external rotation lag
glenohumeral instability test - sulcus sign
What is a shoulder symptom modification procedure?
Clinical techniques introduced into examination with aim of reducing symptoms.
Involves ‘changing’ the position of the scapular or humeral head.
Modifying the thoracic kyphosis (with taping) or using manual therapy
If a rotator cuff is highly irritable how should it be delt with? (e.g. concomitant bursitis)
- advice + education
- load management
- relatice rest
- isometric exercise + graded strengthening of the cuff + scapular muscles
If a rotator cuff is non-irritable how should it be managed?
- advice and education
- graded strengthening of the cuff + scar. muscles
If a rotator cuff is degenerative how should it be managed?
- advice + education
- assisted to independent shoulder exercises
- graded strengthening of the cuff as able
What is a frozen shoulder (adhesive capsulitis)?
Pathological process results in thickening and contracture of the glenohumeral joint capsule.
“Characterised by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule”
Full pathogenesis of frozen shoulder
Trauma/unknown cause leads to an acute inflammatory response.
Chemical mediators create local vasoconstriction which leads to vasodilation in joint capsule (hypo vascular + thickened synovium)
Cytokines alter proliferation which results in excessive fibroblast/myofibroblast activity = excessive collagen synthesis + progressive capsular contraction
Dense collagen matrix laid down in capsule causing reduced joint volume, loss of inferior axillary fold decreasing abduction, coracohumeral ligament. + GH contract decreasing lateral rotation
Stretching of joint aids remodelling of collagen and restores ROM (residual loss may be present)
Stages of frozen shoulder?
- Inflammation (0-3 months) Synovium is inflamed, moderate pain
- Freezing (3-9 months) Synovitis, inflammation + scar formation in underlying capsule. Severe pain
- Frozen (9-15) Minimal pain, stiffness due to scar formation
- Thawing stage (15-24 months) Little pain, movement increases
