Shoulder Injuries Flashcards
What joints are included in the shoulder complex?
- Glenohumeral (G/H)
- Acromioclavicular (A/C)
- Sternoclavicular (S/C)
- Scapulothoracic (S/T)
Where does the long head of biceps attach?
Superior aspect of the labrum
What is the function of the GH labrum?
Deepens the joint & keeps the humeral head centred on the glenoid
What do rotator cuff related conditions include?
- Impingement
- Tendon tears
- Poor control, weakness
What are the types of impingement syndrome of the rotator cuff?
- External (subacromial): Primary, secondary
- Internal (post sup glenoid)
What is primary external impingement syndrome caused by?
Things filling up the supraspinatus outlet:
- Hooked acromion
- Bony spurs
- Coracoacromial ligament thickening
- AC joint OA & osteophytes
What is secondary external impingement syndrome?
- Altered mechanics
- Inadequate muscular stabilisation of scapula
- Dyskinesis causing narrowing subacromial space
What is internal impingement syndrome?
- Joint laxity (usually anterior)
- Dyskinesis
- Results in tendon being drawn into the joint
What is important to remember about impingements?
Not a diagnosis - impingement is caused by something else (usually a combination of factors)
What is an example of dyskinesis in the shoulder?
Abnormal/involuntary movement, e.g. hitching the shoulder during flexion etc
How is primary external impingement treated?
- Need to remove the bony spur with acromioplasty
- Decompression procedure, some of the spur is shaved off
- Coracoacromial ligament is released/removed if thickened
What are the treatment principles for treating impingements?
- Understand primary cause & treat it
- Understand what is modifiable
What are some of the mechanisms of rotator cuff tears?
- Degenerative tendinopathy (usually supraspinatus)
- Pre-existing asymptomatic tendinopathy
- Traumatic tendon rupture e.g. fall, tackle, part of dislocation, huge muscle contraction
What is the most common rotator cuff muscle that is torn traumatically?
Subscapularis
- Blends with anterior capsule
- Helps keep humeral head centred
What are the non-surgical treatment options for rotator cuff tears?
- Activity modification
- Intermittent use of sling
- NSAIDs
- Steroid injections
- Correction of biomechanics
- Strengthening to correct muscle imbalance
- EPAs
For what percentage of patients does non-surgical management of rotator cuff tears provide relief?
Approximately 50%
What type of patients is non-surgical management of rotator cuff tears recommended for?
Patients with pain as the main symptom, rather than weakness (functional strength does not improve without surgery)
What are the 2 proven predictors of poor outcomes from non-surgical treatment of rotator cuff tears?
- Long duration of symptoms (>6-12 months)
- Large tears (>3cm)
When does shoulder instability occur?
- After dislocation
- Weak or uncoordinated rotator cuff
- Attenuated (thinning/stretched) capsule
- Labral tears/SLAP lesions
What keeps the humeral head centred?
A fine balance of capsular ligaments and cuff tendons
What does the rotator cuff cable help to bind?
Supraspinatus and anterior joint capsule
In what direction do G/H dislocations commonly occur?
Anteriorly & inferiorly (people usually in a stop sign position)
What are anterior/inferior shoulder dislocations commonly associated with?
- Bankart lesion (labrum rips off glenoid with humeral head +/- bony avulsion)
- Glenoid rim fracture
- Hill-Sachs lesion (compression fracture of greater tuberosity of humerus)
What can Hill-Sachs lesions be associated with?
Avascular necrosis
What are some of the common subjective findings for shoulder dislocations?
- Acute injury, acute pain
- Prominent acromion, large sulcus under acromion
- Unable to move shoulder until reduced
- Heard popping sound
- Apprehension
Why is it important that shoulder dislocations be reduced quickly?
Can cause an axillary nerve palsy
- Nerve is on stretch when shoulder is dislocated
- Can affect supply to deltoid
What are some of the symptoms that remain after successful shoulder reduction?
- Instability (ant/inf)
- Chronic posterior/multiplanar instability
What are the mechanisms of injury for glenoid labrum tears?
- Traumatic: secondary to dislocation/sublux
- Repetitive overuse: overhead throwing, inferior traction (swinging from arms e.g. gymnasts)
What are the 4 types of SLAP lesions?
- Attachment to glenoid intact, evidence of degeneration/fraying
- Detached superior labrum & long head of biceps
- Meniscoid superior labrum torn away, displaced into joint but tendon & rim intact
- Superior rim tear extends into biceps tendon, both displaced into the joint
What are some of the non-SLAP lesions?
- Vertical glenoid rim lesions
- Degenerative lesions
- Flap lesions
What subjective findings are associated with glenoid labrum tears/SLAP lesions?
- Poorly localised pain in shoulder
- Pain with overhead activities
- Pain with hand behind back movement
- Popping, catching, grinding, clicking
What objective findings are associated with glenoid labrum tears/SLAP lesions?
- Catching mid ROM, blocked ROM or pain at end ROM
- Pain with resisted biceps test
- Dynamic labral shear test, crank test, O’Brien’s test
How are glenoid labrum tears/SLAP lesions managed?
- Pain reduction (avoid painful positions)
- Instability underlying lesion (strengthen stabilisers, closed chain & proprioceptive work)
- Assess & treat hypo/hypermobility
- Refer for surgical opinion
Why are closed chain excesses good for stability?
Compress the joint
How are SLAP lesions repaired surgically?
- Arthroscopically
- Anchor inserted into bone containing sutures & 2 wings
- Once inserted, wings open so sutures are inserted deep into bone & can’t come out
What can post surgical management include?
Depends on surgeon
- Sling
- Pendulum exercises
- AROM/PROM using pulley
- Full ROM
- Throwing
- Overhead activity
What are some of the problems related to stiffness in the shoulder?
- Frozen shoulder
- Post surgery
- Post immobilisation
- Arthropathy (OA/RA)
What is frozen shoulder?
- AKA Adhesive capsulitis
- At least 2 planes of motion restricted (one plane must be external rotation)
- Folds of capsule stick together (freeze up)
- Mechanism unknown
Who is commonly affected by frozen shoulder?
Women around menopause
What is frozen shoulder characterised by?
- Begins with severe pain, often for no reason or only mild trauma
- Pain out of proportion, can’t sleep
- Usually treated poorly (thought to be psychological etc)
What are the phases of frozen shoulder?
- Painful phase (several months)
- Freezing phase - stiffness becomes more prominent than pain
- Thawing phase - movement starts to be restored (can take years)
How is frozen shoulder managed?
- Surgical: Patient under GA, surgeon forces joint back into range
- Cortisone injections
- Physio for loosening stiffness in thawing phase (less pain)
What are some of the common shoulder fractures & their mechanisms?
- Clavicle: FOOSH, fall on point of shoulder, direct blow
- Neck of humerus: FOOSH, OA
- Shaft of humerus: Torsion injury
- Supracondylar humerus: Children
- Greater tuberosity: Compression, shearing off
Why do neck of humerus fractures need to be monitored closely?
Can cause avascular necrosis
How are shoulder fractures managed?
- Clavicle: Sling, figure 8 bandage 2-3/52
- Neck of humerus: U-slab, sling, plastic splint 4/52
- Shaft of humerus: Long arm cast 4-6/52
- Supracondylar: Long arm cast, IF, EF 4/52
What are some of the AC joint related problems?
- Sprains
- Osteolysis
- OA
What is a complication associated with AC joint sprains?
Intra-articular disc in joint can be torn, causing pain & cause of OA over time
When do AC joint injuries commonly hurt?
- Crossing arms
- Raising arms above 90 degrees
(causes compression & rotation at AC joint)
What is osteolysis?
- Erosion/softening of distal end of clavicle
- Can occur spontaneously after AC joint sprain
- Can occur in people who do lots of overheard weights
What is important to remember when looking at AC joint injuries?
Always look at the other end of the clavicle at the SC joint
Where can referred pain from the shoulder come from?
- Cervical spine
- Thoracic outlet syndrome
- Tumours
- Visceral (gall bladder, liver, diaphragm, ulcers, heart, spleen, lung)
- Peripheral nerve entrapments (supra/infrascapular nerve, quadrilateral space, long thoracic nerve palsy)
What are the main static stabilisers of the shoulder in the functional (abducted) position?
- Anterior band of inferior GH ligament (prevents anterior translation)
- Posterior band of inferior GH ligament (prevents posterior translation)
- Glenoid labrum (deepens cavity)
What are the clinical features of rotator cuff tendinopathy?
- Pain with overhead activity
- Ass. symptoms of instability
- Night pain
- Reduced abduction/IR
What complication can occur with rotator cuff tendinopathy?
Calcification (usually in supraspinatus)
What is the mechanism of biceps tendinopathy?
- Large volume of weight training (bench press, dips)
What is the mechanism of subscapularis muscle tears?
Sudden forceful external rotation or extension while in abduction
What nerve entrapments can contribute to shoulder pain?
- Suprascapular nerve
- Long thoracic nerve
- Axillary nerve
What does long thoracic nerve palsy cause?
Paralysis of serratus anterior causing winging of the scapula
What is thoracic outlet syndrome?
- Compression of the neurovascular structures in the thoracic outlet (esp brachial plexus & subclavian vessels
- Occurs in overhead sports
