shoulder injuries Flashcards
AC
• MOI
o Fall onto point of shoulder: rugby tackle, fall from horse
o Direct blow
o FOOSH/elbow
o Acromion is forced inferiorly, anteriorly and medially and this force is transmitted through the AC ligament and coracoclavicular ligament
o Pain is immediate
*Symptoms include immediate pain on the top of the shoulder aggravated by heavy lifting, overhead and across body movements, Swelling +/- bruising
I
Grade 1-2 sprain of AC ligaments and capsule. Most likely to see.
II –most common
Complete tear of AC ligaments
III- most common
Complete tear of AC and coracoclavicular ligaments.
AC Ax
Physical examination
Grade 1: minimal swelling of AC joint, moderate pain with shoulder abduction, minimal pain with passive abduction, minimal pain with abduction and external rotation, minimal to no change in joint play, some tenderness to palpate over ACJ.
Grade 2: Localised tenderness and palpable step deformity
Grade 3: swelling and step deformity, significant pain with AROM and PROM and resistance testing. High symptoms because of ACJ compression. Marked increase in joint play, pain at and around ACJ.
• Diagnostic tool
o Patient actively moves arm into horizontal adduction, therapist applies overpressure
• Positive tests
o Horizontal adduction
o Shrug test
o Possible increase in joint glides
Differential diagnosis
• Subacromial bursitis (imaging)
• Clavicular fracture, distal end
• Chronic manifestation such as osteolysis of the lateral clavicle (seen in weightlifters)
Ac Mx
TDT
• ACJ taping only real measure to all return to functionality
Decrease pain and protect structure • Immobilisation in a sling o 2-3 days for grade 1 o Up to 6 weeks for severe type 2 or type 3 injuries - ice
Manual therapy
• Isometric exercises
o Once pain permits
• Maintain pain free ROM
o AC glides (never glide in the hypermobile direction)
Scapulohumeral rhythm biomechanics - . A-P, P-A, INFERIOR GLIDES
• ESPECIALLY FOR GRADE 3-4
• Alteration is scapular mechanics due to loss of strut function
Return to sport
• Indicated when there is no further localised tenderness and a full range of pain-free movement
• May feel more comfortable in RTS if ACJ is taped.
Surgery is indicated for grade 4, 5, 6 only for grade 3 if conservative Mx fails
ADHESIVE CAPSULITIS
- Adhesions between opposing synovial surfaces with collagen contracture and reactive synovitis
- Painful and limited active and passive glenohumeral range of motion of greater than 25 degrees in at least two directions
• Gradual loss of ROM and increasing pain
• Three stages (over a 2 year period)
o 1: Painful/Freezing: lasts 10-36 weeks occurring spontaneously with increasing shoulder stiffness
- intense burning sensation in the deltoid that radiates down the forearm
o 2: Stiffening/Frozen: lasting 4-12 months
pain in extremes of motion (i.e. overhead activities and behind the back motions). Feels like a dull fullness.
o Trouble sleeping
o Loss of ROML ER, ABD, IR
o Thawing: lasting 5-26 months (includes gradual recovery of range
Prevalence • Females aged 40-60 years • People with diabetes and thyroid problems • Corticosteroid users Patient history
• MOI
o Progressive onset of stiffness in the GHJ
• Complain of:
o Pain will vary depending on the stage (freezing and frozen = most painful)
AD Cap Ax
• Observation
o Muscle atrophy around the shoulder (need to retrain scapular movement and HOH stabilisation and control of scapular motion).
• Movement examination
o LOSS OF BOTH PASSIVE AND ACTIVE ROM
o Ensure the scapula is stabilised and not contributing to the movement
o Pattern of loss of ROM: ER, ABD, MED rotation
♣ Positive sign: loss of ER with elbow at the side (0 deg ABD)
♣ Remember to stabilise scapula when performing
o Will still be stiff and have a loss of ROM even in the thawing stage
o Marked increase in resistance to movement in accessory glides of the GHJ
o Important to assess all planes of motion
Differential diagnosis • Pathologies that often cause loss of ROM at GHJ o Rotator cuff ear o Biceps tendinopathy o SLAP lesion
As Cap man
Nil evidence for mobilisation/physio management. If symptomatic, the physio can be advised to manage pain and/or stiffness via glides.
Aims
• Reduce pain and restore ROM
Advice and education
- largely idiopathic (has no cause).
- secondary to surgery or the trauma you described or could occur as a consequence of joint ageing.
- self-managed and immobilization/ activity modification is not necessary
options
Wait and see
• Resolve spontaneously after 1.5 years
• No evidence that physiotherapy, injections or drugs change the outcome
or
Address pain • Joint mobilisation o Distraction with oscillation- grade 2 o Progress: by grade, duration and position Increase ROM in ER, ABD and Med rotation • Wall walking (abduction) • Muscle/capsule stretches • AAROM
Improve passive ROM (30-60 seconds, 5 sets) PERFORM 5-6 TIMES PER DAY
• Pendulum exercises
o progress: duration
• Cane exercises
o use the non-affected hand to push the affected hand via a cane
o Progress: duration, do actively for as far as you can go then do passively.
o Ensure that scapula is stabilised
• Pulley exercises
o Towel overhead over a beam, hold each end of the towel with your hands and pull
o Progress: duration, number of reps, do actively for as far as you can go then do passively.
Traction helps with PROM as it applies a tensile force to the tissue that is at the end of its length. Do this for ligaments and joint capsules usually, but sometimes muscle also.
Prognosis
• Surgical or post-traumatic stiffness usually resolves in 12 months
• Idiopathic adhesive capsulitis will resolve after 1.5 years, on average (range of 1 to 3 years)
ant. dislocation
Pathophysiology
• forced into excessive ABD and ER with a posteriorly directed force = humeral head forced anteriorly
• Most anterior dislocations damage the attachment of the labrum to the anterior glenoid margin (Bankart Lesion)
• May also be any associated fracture of the anterior glenoid rim (bony Bankart).
• can have axillary nerve damage - impaired sensation on the lateral aspect of the shoulder and deltoid weakness.
Prevalence • Sports persons AFL • Two peaks for patient demographics o 20-30 year old males o 80-90 year old females Patient history • MOI o Acute trauma, either direct or indirect ♣ Fall ♣ Physical assault ♣ Throwing/pulling ♣ Electrocution ♣ Epileptic fit o Associated with sudden onset of shoulder pain o NOTE: not all patients will present as an acute injury – may have instability leading to recurrent subluxation
• Complains of:
o Feeling of the shoulder ‘popping out’
o Pain when sleeping/side lying
o Impaired sensation on lateral aspect of shoulder (axillary nerve involvement)
Ant. disslocation ax
• Observation
o Patient will support arm away from body
o Lean towards side of dislocation
o Prominent humeral head “squared-off deformity”
o Acromion prominent laterally with hollow behind the acromion and defect over the deltoid
o Loss of normal, smooth contour compared to the non-affected side
• Palpation
o HOH may be palpable anteriorly
• Movement exam
o Weakness of deltoid (axillary nerve involvement)
o Glides - Increased AP translation and apprehension
• Positive tests
positive SULCUS SIGN, LOAD AND SHIFT AND SUBLUXATION/RELOCATION
o Sulcus is greater than 2cm
• Diagnostic tool: Glides
o Feel for hypermobility- lax end feel.
o However, never mobilise into plane of hypermobility
♣ i.e. if an inferior dislocation is expected (rare), don’t perform a caudad distraction
Other assessment
• X-ray to rule out fracture Differential diagnosis- rule out: • Bankhart lesion +/- associated fracture of the anterior glenoid rim • Disruption of the GH ligaments • Compression of the HOH posterior (Hill- Sachs lesion) • Humeral head # • Proximal clavicular # • Congenital laxity • RC tears
Ant dislocation tx
Advice and education
• avoid ABD and ER following reduction and SLING NOT USED (IR causes further separation of the Bankart lesion
• bracing- 3 weeks day and night
Medical
• Reduction of the shoulder (in a hospital setting)
• X-ray to investigate any possible fractures
• Surgery (if patient is young)
o Arthroscopic stabilisation of a Bankhart lesion
♣ Immobilisation in a sling in IR for 3-4 weeks (only if lesion has bee repaired)
♣ Gentle pendulum exercises on day one; active ER ROM once pain subsides, then active IR ROM gradually introduced
♣ Strengthening at 6 weeks and RTS generally at 3 months
Physiotherapy aims
o Regain full ROM followed by progressive rotator cuff strengthening
o Neuromuscular control of the humeral head
o RTS
Manual therapy
• Strengthening
o 6 weeks: isometric exercise to strengthen IR
• ROM
o After 3 weeks, the patient can actively ER however combined ER and ABD contraindicated until 6 weeks.
External physical devices
• Splint
o Arm may be placed in a splint to
Neuromuscular control o Centring the HOH in the glenoid ♣ Use rotator cuff muscles ♣ Tape ♣ Visual and tactile feedback
DISSLOCATION
3 GENERAL TERMS OF MANAGEMENT
Conservative appropach
Reduce = ice, Bracing (3 weeks) as sling puts are into further IR which increases Bankart lesion > pendulum >
- Once pain subsides, gentle activations > progress further in to range + load > sports specific drilss > simulated play > RTS if full rom, pain free
- Work on strength and control
- Maintain general fitness
- If doesn’t improve then go into surgery
If repaired/arthroscopy: immobilisation in 3-4wks, Gentle pendulum exercises on day one; active ER ROM once pain subsides, then active IR ROM gradually introduced
- Strengthening at 6 weeks and RTS generally at 3 months
Bony: Post-op protocol (example): § Sling 3 weeks § Then gentle mobilisations § Start strengthening & stabilisation exercises after 4-6 weeks § Full ROM after 8 weeks § Return to sport after ~12 weeks
