Shoulder Impairments Flashcards
What is impingement syndrome?
A general term describing shoulder pain, typically diagnosed following a positive midrange/end-range painful arc and various special tests.
What are the two types of impingement?
- External (Subacromial) Impingement: Pinching of soft tissue structures in the subacromial space (e.g., supraspinatus tendon, subacromial bursa, biceps LH tendon) during humeral elevation.
- Internal Impingement: Impingement of rotator cuff tendons and/or the labrum between the humeral head and glenoid rim.
What structures are affected in external impingement?
• Supraspinatus tendon
• Subacromial bursa
• Biceps long head tendon
Where does internal impingement typically occur?
• Anterosuperior glenoid impingement: Involves subscapularis and labrum.
• Posterosuperior glenoid impingement: Involves supraspinatus, infraspinatus, and labrum.
What is GIRD, and how is it associated with internal impingement?
Glenohumeral Internal Rotation Deficit, often due to posterior capsule contracture.
Who is at risk for internal impingement?
Overhead athletes or those performing loaded tasks at end-range external rotation
What are the two classifications of impingement causes?
- Primary (Structural) Impingement: Mechanical narrowing of the subacromial space.
- Secondary (Functional) Impingement: Functional disturbances affecting humeral head positioning in the GH joint.
What factors cause primary impingement?
• Bony narrowing or malpositioning (e.g., after trauma, scarring).
• Structural variation in acromion (Type I: flat; Type III: hooked).
• Fibrosis/thickening of the coracoacromial ligament.
• Trophic changes to the humeral head, AC joint, or coracoacromial arch.
• Vascular changes in rotator cuff tendons (e.g., due to age or secondary disease).
What are functional causes of secondary impingement?
• Posterior capsule tightness: Causes anterosuperior translation of the humeral head.
• Weak external rotators/short internal rotators: Limits external rotation during abduction, preventing the greater tubercle from clearing the acromion.
• Deltoid overpowering rotator cuff: Results in superior translation of the humeral head.
• Poor scapular stability/muscular imbalances: Disrupts the length-tension relationship of the rotator cuff.
• Hyperkyphosis: Positions the scapula in downward rotation, protraction, and posterior tipping, causing internal rotation of the humerus.
• Rotator cuff/biceps LH overuse and fatigue: Reduces dynamic stabilizing forces.
• Lax connective tissue: Allows excessive humeral head translation.
• Labral or rotator cuff tears: Create instability.
Repeated dislocation: Causes ligament damage or scarring, leading to excessive movement.
What are the potential impairments caused by impingement syndromes?
Tendinopathy:
• Tendonitis (inflammation/edema decreases subacromial space).
Tendinosis (thickening/fibrosis of tendons with chronic inflammation reduces subacromial space).
Bursitis:
• Often presents with tendinopathy.
• Can cause acute burning/sharp pain and painful “catch” when lowering the arm from abduction.
Rotator Cuff Tears:
• Partial or full-thickness tears from trauma or overuse.
• Poor posture and mechanics predispose to these injuries.
How does supraspinatus tendinopathy present?
• Pain on palpation inferior to the anterior acromion.
• Painful GH arc.
• Positive impingement tests.
How does infraspinatus tendinopathy present?
• Pain on palpation inferior to the posterior acromion when the patient externally rotates and horizontally adducts.
• Painful GH arc with abduction and flexion.
How does biceps long head tendinopathy present?
• Pain on palpation of the bicipital groove.
• Positive Speed’s test.
What causes partial-thickness rotator cuff tears, and how are they treated?
Causes: Chronic inflammation, spurs under the acromion, arthritis, overcontraction, or overstretch.
Treatment:
• Modified activity (limit overhead movements/lifting).
• Progressive rehabilitation through healing stages (acute to chronic).
What causes full-thickness rotator cuff tears, and how are they treated?
Causes: Trauma, heavy lifting, or unresolved partial tears.
Treatment:
• Modified activity.
• Progressive rehabilitation.
• Arthroscopic surgery may be needed to repair tears and shave bone spurs.
What are the treatment goals and techniques for the acute phase of impingement?
Goals: Control inflammation, promote healing.
Techniques:
• Superficial fluid techniques.
• Lymphatic drainage.
• Spasm techniques.
• Low-grade joint mobilization.
What are the treatment goals and techniques for the subacute phase of impingement?
Goals: Eliminate residual inflammation, maintain tissue extensibility, and prevent adhesions.
Techniques:
• Myofascial release (MFR).
• Trigger point (TrP) techniques.
• Decrease UMRT (upper muscle resting tension).
• Isometric exercises.
• Passive stretching.
• Low-to-high grade joint mobilization.
What are the treatment goals and techniques for the chronic phase of impingement?
Goals: Increase tissue extensibility, ROM, and mobilize scar tissue.
Techniques:
• Myofascial release (MFR).
• Frictions (if applicable).
• Decrease UMRT.
• TrP techniques.
• Passive stretching.
• High-grade joint mobilization.
• Isotonic and functional exercises.
What should treatment for secondary impingement focus on?
Identifying and treating the root cause, as secondary impingement often results from poor mechanics.
How can chronic inflammation and tendon overload further complicate impingement syndromes?
They can stimulate osteophyte formation, leading to further damage to surrounding musculature.
What is primary frozen shoulder (adhesive capsulitis)?
A condition characterized by dense adhesions, capsular thickening, and restrictions of the GH joint, leading to pain and limited motion.
What are the four stages of frozen shoulder?
- Stage 1:
• Gradual onset of pain, especially at night.
• Loss of external rotation.
• Duration: <3 months. - Stage 2 (“Freezing”):
• Persistent pain at rest and with movement.
• GH motion limited in all directions.
• Duration: 3–9 months. - Stage 3 (“Frozen”):
• Pain only with movement.
• Significant adhesions, limited GH motion, scapular compensations.
• Duration: 9–15 months. - Stage 4 (“Thawing”):
• Minimal pain, no inflammation.
• Gradual improvement in motion (may not regain full ROM).
• Duration: 15–24 months.
What are common characteristics of primary frozen shoulder?
• Insidious onset, typically in individuals aged 40–60.
• More prevalent in women.
• May be linked to chronic inflammation in rotator cuff, biceps tendon, or GH capsule.
What distinguishes secondary frozen shoulder?
• Occurs due to another issue like OA, RA, trauma, or prolonged immobilization.
What impairments are commonly seen with frozen shoulder?
• Night pain and disturbed sleep.
• Pain with motion and sometimes at rest (stage-dependent).
• Decreased GH joint play in a capsular pattern:
1. External rotation.
2. Abduction.
3. Internal rotation.
4. Flexion.
• Faulty posture: protracted and anteriorly tilted scapula, internal rotation, and shoulder elevation.
• Reduced arm swing during gait.
• Neck pain due to overuse of UFT, levator scapula, and posterior cervical muscles.
What are the treatment goals for stages 1 and 2 of frozen shoulder?
• Control pain, edema, and muscle guarding.
• Prevent adhesion formation.
What are the treatment goals for stage 3?
• Control pain and edema.
• Increase joint and soft tissue mobility.
• Improve joint mechanics and muscle function.
What are the treatment goals for stage 4?
• Increase tissue mobility and extensibility.
• Enhance muscle performance.
• Return to functional activity.
What techniques are used in stages 1 and 2?
• Lymphatic drainage, superficial fluid techniques.
• Gentle spasm techniques (GTO, reciprocal inhibition).
• Low-grade joint mobilization.
• Pain-free PROM, pendulum exercises.
• Gentle muscle setting and relaxation techniques.
What techniques are used in stage 3?
• Myofascial release, trigger point techniques.
• Low-to-high grade joint mobilization.
• Pain-free AAROM, self-assisted ROM, active ROM.
• Movement retraining, isometric to isotonic strengthening.
• PNF and self-stretching.
What techniques are used in stage 4?
• High-grade joint mobilization.
• Myofascial release, trigger point therapy, and frictions.
• Isotonic and functional exercises.
• PNF and self-stretching.
What factors may contribute to secondary frozen shoulder?
• Tight internal rotators, especially subscapularis.
• Tight anterior/inferior GH capsule.
• Hyperkyphosis, placing the humerus into internal rotation.
• Diabetes, due to vascular and neurological changes affecting the upper limb.
What is a key precaution in treating frozen shoulder?
Avoid overly aggressive therapy, as it may prolong symptoms.
What are the causes of labral tears?
Traumatic events or overuse, particularly in overhead athletes (e.g., baseball, volleyball).
What are the types of labral tears?
- Bankart Lesion:
• Detachment of anterior capsule and glenoid labrum.
• Involves inferior GH ligament.
• Caused by force in abduction and external rotation. - SLAP Lesion:
• Superior Labrum, Anterior to Posterior tear.
• Involves biceps long head tendon.
• Caused by trauma (e.g., FOOSH, MVA) or repetitive overhead motion.
Subtypes:
• Type 1: Partial tear; rough and frayed edges (Tx: Debridement).
• Type 2: Superior labrum torn off glenoid (Tx: Arthroscopic reattachment).
• Type 3: Bucket-handle tear causing popping/locking (Tx: Remove bucket handle and reattach labrum).
• Type 4: Tear extends into biceps LH (Tx: Reattach labrum and biceps). - Reverse Bankart Lesion:
• Posteroinferior labrum tear, involving posterior band of the inferior GH ligament.
• Typically occurs with posterior dislocation.
What is a Hill-Sachs lesion?
A compression fracture of the posterior humeral head due to contact with the anterior glenoid rim during anterior dislocation.
What are the key points about Hill-Sachs lesions?
• Commonly accompanies a Bankart lesion.
• May or may not require surgical repair based on size.
• Can perpetuate shoulder instability.
• Reverse Hill-Sachs Lesion: Occurs during posterior dislocation, often with a Reverse Bankart lesion.
What are the most common directions of shoulder dislocations?
• Anterior dislocations (90+%).
• Posterior dislocations are less common.
• Can also occur inferiorly or superiorly.
What causes anterior dislocations?
A posterior force to the shoulder with the humerus in external rotation and abduction.
What injuries commonly accompany anterior dislocations?
• Bankart labral lesion.
• Hill-Sachs fracture.
• Stretching or tearing of anterior capsule and rotator cuff muscles.
• Potential nerve and blood vessel involvement.
What causes posterior dislocations?
An anterior force with the humerus in flexion, adduction, and internal rotation.
How do posterior dislocations typically occur?
• FOOSH injuries.
• Motor vehicle accidents (MVA).
• Often accompanied by Reverse Bankart lesion and Reverse Hill-Sachs fracture.
How are dislocations managed acutely?
• Reduction techniques using traction-countertraction.
• Early reduction reduces muscle spasm and neurovascular compression.
• Immobilization in a sling for 3–4 weeks.
What is the rehabilitation protocol after a shoulder dislocation?
- 3 Weeks Post-Injury: AAROM with limited external rotation.
- 4–6 Weeks Post-Injury: Pendulum exercises and scapular retractions.
- 7–8 Weeks Post-Injury: AROM with limited external rotation, isometric rotator cuff and scapular retraining.
- 9–12 Weeks Post-Injury: AROM with end-range stretching and isotonic exercises.
- 3 Months Post-Injury: Non-contact sports with no overhead activity.
- 4 Months Post-Injury: Contact sports with overhead activity.
When is surgery indicated for dislocations?
• Recurrent dislocations or subluxations.
• Significant capsular or ligamentous laxity.
• Young, athletic patients unwilling to modify ADLs.
What is a shoulder separation?
An injury to the acromioclavicular (AC) joint, ranging from a sprain to a full separation of the clavicle from the acromion.
What are the grades of shoulder separation?
• Grade 1: Sprain of AC ligament; no separation.
• Grade 2: Rupture of AC ligament; sprain of coracoclavicular (CC) ligament; slight displacement of clavicle.
• Grade 3: Rupture of AC and CC ligaments; full separation of clavicle from acromion.
What is the mechanism of injury (MOI) for shoulder separation?
• Common in athletes, especially in contact sports (hockey, rugby, football).
• Caused by a direct blow to the shoulder or a FOOSH (fall on outstretched hand).
How is shoulder separation treated?
• Grade 1–2: NSAIDs, ice, immobilization (1–3 weeks), taping for stability, therapeutic exercise.
• Grade 3: May require surgery.
Why are SC joint injuries uncommon?
The SC joint is very stable with strong ligamentous support, and the clavicle typically fractures before the SC joint dislocates.
What are the degrees of SC joint injury?
• 1st Degree: Sprain of the SC ligament.
• 2nd Degree: Complete tear of SC ligament; partial tear of CC ligament; clavicle subluxes from manubrium.
• 3rd Degree: Complete rupture of SC and CC ligaments; dislocation of clavicle from manubrium.
How are SC joint injuries treated?
• NSAIDs, ice, immobilization.
• Rarely requires stabilization surgery, which typically involves a tendon graft (e.g., palmaris longus).
How common is osteoarthritis in the shoulder?
Less common than in weight-bearing joints.
What are the symptoms of shoulder osteoarthritis?
• Stiffness, pain, and decreased ROM.
• Pain worsens in the morning, after immobility, or with excessive activity.
• Pain may disrupt sleep, especially when lying on the affected side.
What causes shoulder osteoarthritis?
• Previous trauma, instability/laxity.
• Inflammatory conditions or overuse, particularly from high-intensity overhead activities.
How is shoulder osteoarthritis treated?
• Conservative treatments: Massage, therapeutic exercise (optimize posture, maintain/increase ROM, strengthen surrounding musculature).
• NSAIDs or steroid/hyaluronic injections.
• Surgical options: Arthroscopic cleaning (resurfacing, removing bone spurs) or full joint replacement.
