Shoulder examination Flashcards
Name the 4 joints in the shoulder complex
SC joint
ST joint
GH joint
AC joint
What % does the glenoid cover the humeral head?
25-30%
What position is the glenoid directed to ?
Anterior and lateral
Subacromial bursa
Size of bursa compared to others in body? Position? Vascularised? Innervation?
Largest in the body
Lies between deltoid + coracoacromial arch superiorly and Rotator cuff inferiorly
Well vascularised
Highly innervated with both proprioceptive and nociceptive endings
Kolk et al (2017) and Budoff et al (2005) findings related to bursectomy renders acromioplasty
Inneffectvie method
Rotator cuff description
Tendons of RC interweave and interdigitate as they attach to the humerus, forming a broad, confluent attachemnt, which involves the GHJ capsule and coracohumeral ligament.
Impossivle for tendons to be seperate entities, stress of any part of RC will involve all structures.
What is the primary purpose of the shoulder complex?
To place and control the hand in front of the body.
Scapular activity during elevation of the arm
Muscles involved? What movements do they allow?
Trapezius and serratus anterior
Upper trapezius - upward rot, retr + elev
Lower trapezius – upward rot, retr + dep
Serratus anterior – upward rot + pro
Scapular winging
When the muscle sof the scapula are weak or paralysed, resulting in limited ability to stabilise the scapula.
As a result the lateral borders of the scapula protrudes from back, like wings.
Muscle activity during elevation of the arm
Deltoid prime mover at the GHJ.
Infra/teres minor + subscapularis act as force couple to counteract upward pull of deltoid
RC exerts medial force on humeral head which approximates it to glenoid.
Long head of bicep exerts downard force, as long as humeral head centres on glenoid and not inf translated.
Shoulder instability
What does it depend on? What does it result from?
Depends upon fibrous tissue restraints and dynamic muscular action.
Instability results from inefficiency of the coraco and glenohumeral ligaments +/- rotator cuff.
Serratus anterior and traps contribute by way of scapular control
Not necessarily linked to a specific event but is often due to repeptive forces applied at rate that exceeds that of tissue repair.
GH ligament
Three ligaments on the anterior side of the shoulder joint.
They extend from the humerus to the glenoid fossa and reinforce the joint capsule.
Movements that tighten the anterior and posterior portions of the inferior glenohumeral ligament.
Abduction and external rotation - tighten anterior
Horizontal abduction and medial rotation tighten - postieror portion
Types of instability
Anterior
Posterior
Inferior
Clinical features of shoulder instability
History and exam.
History: dull ache; often do not c/o of instability, but more apprehension, a feeling something “not quite right”; fatigue; dead arm syndrome; family Hx; pain at night whether lying on either
side. If they do c/o shoulder “coming out” - does it come out all the way? how does it go back in? - disloc/sublux. Crucially, what posn is the shoulder when pt experiences Sx? → nature of any instability.
Clinical features of shoulder instability- exam
Atrophy; posn humeral head; ROM often full, but some pain end of flex/abd; weak cuff – possible tear; demonstrate instability?; generalized laxity?; +ve instability tests; possible +ve lag signs;
possible biceps tear/tendinopathy; possible labral tear
Clinical features of shoulder instability
Patterns of weakness and/or restriction
May be a degree of global cuff weakness
Often most painful shoulder conditions, is characterised by identifiable patterns of specific cuff weakness and resitriction/laxity of non-contractile tissues, primarily capsuloligamentous complexes.
Identifying, recognising and understanding these patterns of weakness and resticiton/laxity is important in diagnosis and crucial in delivering effective treatment.
Factors limiting anterior translation
**Dynamic resistance- **
Primary: Posterior cuff (infra + teres minor)
Secondary: long head of biceps; global cuff
**Non-contractile resistance- **
Primary: Anterior band inferior GHL
Secondary: coracohumeral lgt, superior GHL, middle GHL, anterior capsule.
Factors limiting posterior translation
Dynamic resistance
Primary: anterior cuff (subscapularis)
Secondary: global cuff
Non-contractile resistance
Primary: posterior band inferior GHL
Secondary: posterior capsule
Factors limiting inferior translation
Dynamic resistance
Primary: Superior cuff (Supraspinatus), global cuff
Non-contractile resistance
Primary: dependent posn- sup jt cap + superior GHL,
coracohumeral lgt + superior jt capsule
>45deg abduction - inferior GHL
Secondary:-ve intra-articular pressure
What is typical pattern for athletes with anterior instability and what does it indicate
Increased external rotation
Decreased internal rotation
Often indicates comparative restriction/laxity
of post/ant capsule
Impingement syndrome
Refers to symptoms of pain and dysfunction resulting from any pathologywhich either decreases the volume of the subacromial space or increases the size of its contents.
Primary impingement
acromial morphology;
osteophytes; thickened cuff; calcific
bursa/tendon; fracture; a-c dislocation; OA/RA;
bony kyphosis/scoliosis
Secondary impingment
Posture; weakness;
instability; ergonomics; neuropathy; muscle
imbalance
Primary inflammation/degenrative changes for shoulder impingement
Tendinitis/osis; bursitis; synovitis; capsulitis; cuff
tears; ageing
Clinical features of subacromial impingement - History
V common in > 45 yrs
Usually gradual onset with Hx of oversue involving repetitive abd/flex posn eg gardening, DIY, moving house, pain on reaching, lying on affected side.
If severe, pain can spread down arm to hand. If sudden onset, may indicate tear; weakness; struggling to sleep.
Clinical features of subacromial impingement- exam
Painful flex/abd, but full passive movt; weak cuff – pain
inhibition or possible tear?; +ve impingement tests; possible +ve lag
signs; may have co-existing instability
Anatomical and aetiological relationship between impingement and instability
Both interconnected.
If primary lesion is instability, RC will attempt to resist abnormal translation of hum head leading to primary inflam of RC + consequent impingement. Also, increased movt of hum head may in itself decrease s-a space enough to pinch RC.
If primary lesion is impingement, RC will become painful, weak + fatigue easily leading to overload of passive restraints which will eventually lead to laxity + instability.
Treatment for impingement
Selective rest
Rehabilitation – must be rational, appropriate and
progressive; scap muscles before cuff. Also include
correction of faulty technique/posture
Injection– no unanimity re route, drug, dosage,
technique, asepsis, post-inj protocol
Surgery– subacromial decompression; cuff repair
Clinical features of adhesive capsulitis-
History
Gradual onset increased pain + stiffness; can be precipitated by trauma, but usually idiopathic; most common atraumatically 45- 75 yrs but any age is poss; pain on reaching up + back, doing
up bra, back pocket; pattern of pain will depend upon stage of condition.
Adhesive capsulitis
Involves initial inflam stage followed by restriction/contraction of g-h capsule
Clinical features of adhesive capsulitus
Exam
Characteristic pattern of limitation of the shoulder
capsular pattern – ltd abd, less ltd flex, more ltd LR; if passive lateral rotation is full range, then it is NOT a frozen shoulder; if passive lateral rotation is full range and painless, then there is nothing wrong with the capsule; -ve impingement tests.
Adhesive capsulitis stages
Stage I - Pain
Stage II - Pain and stiffness
Stage III - Stiffness and pain
Stage IV– Recovery
Adhesive capsulitis treatment
Stage I and II – injection. Any other pain relieving
modality - TENS, mobilisations, NSAIDS/analgesics,
active movts
Stage III – time. Mobs/manips may give short term
increase in range, but long term do little and possibly
increase soreness over time
Stage IV – Rx usually unnecessary. Sometimes
exercises/mobilisations to increase HBB
