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Patho 2 > Shoulder Pathologies > Flashcards

Shoulder Pathologies Flashcards

1
Q

Common Tendinopathy in UL

A 
Rotator Cuff Related Pain
Lateral Epicondylitis (Tennis elbow)
Medial Epicondylitis (Golfer's elbow)
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2
Q

Define Rotator Cuff Shoulder Related Pain (RCRSP)

A

Most common tendinopathy of upper limb
Includes:
• Sub-acromial pain syndrome (Impingement) - bursitis
• Rotator Cuff Tendinopathy
• Rotator Cuff Tears - including long head biceps brachii tear

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3
Q

Pathogenesis of rotator cuff tendinopathy

A

Extrinsic factors:

  1. Mechanical irritation of contents of subacromial space compression between greater tubercle and upper part of glenoid causes superior slide of humeral head in glenoid
  2. Postural dysfunction - FHP, protracted shoulder girdle, kyphosis, scapula position; Leads to alteration of force couples operating around shoulder & faulty movements
  3. Muscle imbalances:
    1. Weak / fatigued / injured rotator cuff
    2. Results in loss of deltoid: RC force couple
    3. Allows superior migration of humeral head
    4. Leading to repetitive impingement of subacromial soft tissue
    5. Results in inflammation & rotator cuff disease
  4. Impingement of rotator cuff tendons secondary to G/H instability = Failure of static or dynamic stabilisers of GH joint allows excessive translation of HH
  5. Occupational / environmental / training: Anything that involves repetitive overhead manoeuvres eg. Tennis; painting ceiling; stacking shelves

Intrinsic Factors:

Degeneration of RC tendons

Deconditioned tendon - An under loaded tendon has no stimulus to build healthy tissue, will fail if suddenly over loaded

Joint side wear & tear

  1. Acromial side RC tendon fibres thicker & stronger
  2. Joint side fibres more vulnerable to tensile loads
  3. Lesions often found on joint side of tendon not acromial side
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4
Q

Risk factors of rotator cuff shoulder related pain

A

Age 35-75

H/O repetitive movements at or above shoulder height, or of heavy lifting

Athletes, workers who perform overhead activities and the elderly

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5
Q

Clinical presentation of rotator cuff shoulder related pain

A

Altered scapular movement therefore have changes in scapulohumeral rhythm

Pain in the top and lateral side of the shoulder which is made worse by lifting the arm (for example when lifting a full kettle) or with overhead activities

There can be night pain

Active movements are painful and may be restricted, whereas passive movements tend to be full but painful

May be a painful arc of movement between 70-120 degrees of abduction (presence reinforces the diagnosis of a rotator cuff disorder)

Weakness &/or pain on isometric resisted testing - joint does very little mvt

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6
Q

Management of RCSRP

A

○ Surgery vs Physiotherapy - some evidence suggests that they have similar outcomes

○ Physiotherapy includes:

Load modification - at first progression back to normal activities as soon as pain allows

Education - on pathology and on reducing aggravating activities

Pain relief - NSAIDs / Ice / joint mobs / SSTMs

Exercise:

Improve Strength and tissue capacity

Exercise in one direction at a time eg. ER

Restore full AROM & PROM

Isometrics (if irritable)> Isotonic

Start slow (this biases muscle, fast exs biases tendon)

Don’t exercise at EOR

Work into ER – this increases SAS & decreases pressure on RC tendons

Add other movements (e.g. LR with abd)

Progressive dynamic strengthening of RC

Maintain & improve neuromuscular control

Maintain muscle strength of all shoulder muscles

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7
Q

Define Adhesive Capsulitis (frozen shoulder)

A

Formation of excessive scar tissue or adhesions across the glenohumeral joint leading to stiffness, pain and dysfunction
Affects glenohumeral ligaments and joint capsule

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8
Q

Prevalence of frozen shoulder

A

Common, debilitating condition

Reported prevalence of 2-5%

Most common in 40-60 year age group

Affects women > men

Characterised by pain & stiffness in the shoulder which passes through 3 stages

20% incidence in patients with diabetes

Bilateral involvement in up to 40-50% of cases

Self-limiting condition - 3 consecutive phases; spontaneous resolution

Prognosis - Mean duration from onset to recovery: 30 months

Usually leads to full functional recovery within 1-4 years but studies show 20-50% of patients had permanent restriction to movement compared to the uninvolved side, however, only 11% reported residual functional limitations

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9
Q

Types of Frozen Shoulder

A

Primary (idiopathic) - occurs spontaneously
Secondary – often after trauma, e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis

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10
Q

Risk factors of Frozen Shoulder

A

Female (70%) > Male (Males respond less well to treatment)

Previous AC in other arm

Age >40

Trauma - e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis

HLA-B27 +ve - blood test indicating if high risk of developing autoimmune diseases

Ankylosing spondylitis

Reactive arthritis

Cerebrovascular Disease

Coronary Artery Disease

Diabetes - 20% incidence; these patients have worst outcomes - more likely to have longer lasting symptoms, bilateral symptoms, recurrence

Hyperthyroidism

Previous/current Dupuytren’s disease

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11
Q

Stage 1/3 of Frozen Shoulder Pathology

A

Painful (Freezing) Phase (2-9 months)

Primary complaint of shoulder pain, especially at night

Arthroscopically – evidence of synovitis (inflammation of synovium) without adhesions

Histologically inflammatory cell infiltration of the synovium

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12
Q

Stage 2/3 of Frozen Shoulder Pathology

A

Stiff (Frozen) Phase (4-12 months)

The pain becomes less severe but is present at the EOR. Stiffness remains and there

is reduction in the range of shoulder movements. Function can be substantially limited.

Arthroscopically synovitis is resolved (inflammation settled), significant adhesions – axillary fold obliterated

Histologically - Dense collagenous tissue within capsule

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13
Q

Stage 3 of Frozen Shoulder Pathology

A

Recovery (Thawing) Phase (12-42 months)

Gradual improvement in range of movement with less stiffness

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14
Q

Clinical presentation of Frozen Shoulder

A

Usually present first with gradual onset of shoulder pain & is felt at deltoid region

Followed by painful and gradual loss of AROM & PROM in capsular pattern (LR > Abd > MR)

AROM/PROM affected as inert tissue affected by adhesions formed

Decreased ER on AROM & PROM is usually sufficiently diagnostic; seen as difficulty putting on jacket

Passive ROM with firm, painful end feel

Inability to sleep on affected side

X-rays = normal - Imaging not necessary for diagnosis but can rule out other conditions, i.e. OA, pancoast tumour - lung cancer at apex of the lungs; <1% patients of stiff shoulder have this; 25% patients w/ this tumour have delayed diagnosis because of misdiagnosed shoulder problems

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15
Q

Medical management of Frozen Shoulder

A
  • NSAIDs
  • Corticosteroid Injections - reduce pain and inflammation
  • Hydrodilatation - injection of large amount of fluid into shoulder joint capsule to stretch it out and tear adhesions apart (Less invasive than surgery)
  • Surgery - 2 types: Capsular Release (safer than MUA), MUA (Manipulation under anaesthesia)
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16
Q

Physiotherapy management of Frozen Shoulder

A

Early mobilisation

Early pain management is key to allow this
Manual therapy and exercises included

Education

the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover

Determine:-

  1. main problems
  2. phase 1,2 or 3
  3. SIN factors - pain will be guiding factor to alter rehab: stretches to discomfort but not to pain

Painful phase:

Key aim: reduce pain

<3/12 consider CSI

>3/12 avoid CSI - seems to increase length of time of resolution

NSAIDs?

ADVICE - the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover

Maximise ROM

Freezing phase

Key aim: maximise ROM and function

Mobs

Self-management programme - RC interval (supero-anterior capsule) stretched in neutral ER

Advice

Resolution phase

Key aim: maximise ROM restore function

Active exercise programme /self-management programme

Mobilisation/stretching

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17
Q

Prevalence of Clavicle #

A

Mostly result from a fall, normally on to shoulder - fall on side of shoulder or FOOSH
Neuro / vascular structures nearby can be affected, i.e. brachial plexus, subclavian vessels
Mid-shaft (most common) > Lateral (2nd most common) > Medial (4.5% of clavicle #)

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18
Q

Medical management of clavicle #

A

Surgical - more severe injuries - displaced #
Similar physio treatment post-op

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19
Q

Physiotherapy management of clavicle #

A

Conservative - less severe injuries - non-displaced #
Sling use - usually 3 weeks
Physiotherapy - involves early mobilisation of shoulder and shoulder girdle, progression into loading, as appropriate

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20
Q

Prevalence of proximal humerus #

A

Normally occurs as a result of a fall
Third most common fractures in the elderly, more common in women (2:1)
Classified depending on how many fragments are displaced:
1-part # = no displacements
2-part # = 1 displacement
3-part # = 2 displacements
4-part # = 3 displacements

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21
Q

Management of proximal humerus #

A

Collar and cuff (2-3/52) - type of sling with a pink foam material
Followed by progressive active management
The more elderly the patient the slower they progress and are more likely to be left with reduced ROM and function post-treatment; could result in frozen shoulder
Surgery - most severe cases require surgical fixation

22
Q

Prevalence of OA

A

○ Most common form of arthritis, can develop in any synovial joint.
○ Most common in knees, hips and small joints of hand.

23
Q

Medical management of OA

A

Corticosteroid Injection
Surgery - most severe cases; joint replacements (common), debridement

24
Q

Physiotherapy management of OA

A

§ Exercises for mobility and strength
Hydrotherapy - different form of exercises in hydrotherapy pool; warmer (34oC) than standard pool, providing therapeutic affect; buoyancy of pool also provides a therapeutic affect
Manual therapy
Education

25
Q

Define Rheumatoid Arthritis (RA)

A

Systemic autoimmune disease (body’s immune system attacks the joint) characterised by inflammatory arthritis with extra-articular involvement

26
Q

Pathology of RA

A

Synovium is infiltrated by immune cells.
Fibroblasts and inflammatory cells lead to osteoclast generation resulting in bone erosion and loss of joint integrity.
Systemic inflammation and autoimmunity in RA begin long before the onset of joint inflammation

27
Q

Prevalence of RA

A

○ Most prevalent in North America and Northern Europe
○ Female > Male - 2-3:1
○ Prevalence increases with age
○ Paediatric population – RA = Juvenile Idiopathic Arthritis; Idiopathic = occurs spontaneously or w/out a known cause
○ Polyarthritis of small joints of hands – PIP, MCP, RCJ
○ Other commonly affected joints – elbows, shoulders, hips, knees, ankles, MTP

28
Q

Risk factors of RA

A

Genetic Factors (non-modifiable)

Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D

29
Q

Clinical Presentation of RA

A

○ Insidious (gradual) onset over a period of months
○ Joint stiffness in the morning
○ Fatigue
○ Deformity (formed overtime due to bone erosion and loss of joint integrity)
○ Pain
○ Weakness and restricted mobility in affected joints
○ If Cx is involved it can lead to cervical instability between C1 and C2 - affecting dens and surrounding ligts = reducing stability

30
Q

Medical management of RA

A 
GOAL = symptom management 
Pharmacological management (key treatment) – Disease Modifying Anti-Rheumatic Drugs (DMARDs) 
Nutrition - help with symptom management
31
Q

Physiotherapy management of RA

A

Appropriate exercise programme to maintain mobility, strength and function for as long as possible; also to manage flare-ups
Advice and education

32
Q

Define shoulder dislocation

A

Dislocation can occur anteriorly or posteriorly (<5%) - humeral head dis-articulates either anteriorly/posteriorly

33
Q

What are the static and dynamic shoulder stabilisers

A

ANATOMIC:

Labrum: triangular fibrocartilaginous rim attached around margins of fossa & improves joint congruency as well as providing a surface of attachment for glenohumeral ligaments

Continuous with biceps long head tendon – important for SLAP lesions

Negative intra-articular pressure

STATIC: Capsuligamentous structures

Ligaments:

  1. Glenohumeral ligaments:(thickenings of anterior capsule; superior, middle & inferior)
  2. Inferior g/h ligament most important in preventing anterior & inferior translation
  3. Middle g/h ligament resists ER & abd

Rotator cuff tendons blend with & re-inforce capsule superiorly by supraspinatus, anteriorly by subscapularis, posteriorly by teres minor & infraspinatus

Coracohumeral lig + superior capsule + inactive supraspinatus provide static stabilisation in dependent arm

Capsule:

  1. Capsule is thin & is strengthened by the ligaments (glenohumeral & coracohumeral) & the muscles. Inferior part of capsule is thinnest, dislocation most common in this direction.
  2. Lax capsule allows large ROM
  3. Tight inferiorly on abd.
  4. Tight ant on ER
  5. Tight post on IR

DYNAMIC:

Rotator cuff:

Reinforce capsule – static stability

Provide dynamic stability

Produce compressive force

Maintain optimal relationship of HH with glenoid through ROM - resist & control HH translation

Maintain sub-acromial space & Prevent impingement

Any imbalance in RC can lead to disturbed S-H rhythm & dysfunction eg. impingement

Supraspinatus & deltoid important compressors at 90° abd.

Subscap. important in decreasing displacement aided by infraspinatus

Rotator crescent = area of relative avascularity approx 1cm from insertion of supraspinatus & infraspinatus tendons

Stability heavily dependent on muscles to maintain integrity

Structures limiting inferior translation:

  1. Negative intra-articular pressure
  2. Superior GH ligament

Structures limiting anterior translation:

  1. Anterior capsule and ligs - GHL
  2. Subscapularis & long head of biceps tendon
  3. Inferior GH ligament (in abduction)

Structures limiting posterior translation:

  1. Posterior capsule
  2. Inferior GH ligament
  3. Teres minor & infraspinatus tendons
34
Q

Pathology of Anterior Shoulder Dislocation

A

Movement on its own = anterior glide of humeral head on glenoid fossa
Inferior GH ligt = primary ligamentous restraint to ant displacement

35
Q

Prevalence of Anterior Shoulder Dislocation

A

Often caused by the arm being positioned in abduction and external rotation (apprehension position); apprehension position used for shoulder instability tests
In this position there is often a AP force resulting in humeral head displacing antero-inferiorly
Can result in many types of lesions
Concurrent rotator cuff injuries can also occur
Vascular / neural structures at risk - particularly structures w/in axilla and brachial plexus

36
Q

What lesions can an Anterior Shoulder Dislocation result in

A

Hills-Sachs lesion - small # or cortical depression (depression in bone) on posterolateral aspect of humeral head; caused by impaction of humeral head against rim of the glenoid as dislocation occurs
Bankart lesion - damage to attachment point of the labrum to the glenoid margin; normally occurs anteriorly to anterior dislocation; Bony Bankart lesion = if associated w/ # of glenoid sometimes
Superior Labrum Anterior and Posterior (SLAP) lesion - Tears of the superior labrum near to the origin of the long head of biceps; common in throwing athletes
Humeral Avulsion Glenohumeral Ligament (HAGL) lesion - Inferior Glenohumeral Ligament is ripped off the humerus with dislocation of the shoulder
Anterior Labral Periosteal Sleeve Avulsion (ALPSA) lesion - the anterior labro-ligamentous complex rolls up in a sleeve -like fashion and becomes displaced medially and inferiorly, “the medialised Bankart lesion”

37
Q

Prevalence of Posterior Shoulder Dislocation

A

Usually caused by a blow to the front of the shoulder often with the arm flexed at the shoulder in adduction and internal rotation

Can also occur during seizures or electrocutions

Can be easily overlooked on an AP x-ray

Concurrent injuries to rotator cuff (mainly subscap) and posterior labrum, HOH # (can progress to AVN or OA)

On examination person may hold the shoulder in adduction and internal rotation. There may be an abnormal shoulder contour

38
Q

Prognosis of shoulder dislocations

A

19.6% recurrence rate, mostly in first two years
Higher recurrence rate in males
Higher recurrence in younger patients (49.2% if aged 10-19)
Those with recurrence are more likely to have a shoulder stabilisation surgery

39
Q

Define Shoulder Instability

A

Unable to control or stabilise the joint during motion or in a static position either because static restraints have been injured or because muscle controlling the joint are weak or the force couples are unbalanced

Characterised by disruption of the dynamic and static stabilisers of the GHJ leading to subluxation (partial loss of contact between joint surfaces) or dislocation (the complete loss of contact between joint surfaces) or apprehension

40
Q

Causes of Shoulder Instability

A

Traumatic (96%):

Shoulder is dislocated by an external force

As the shoulder does not heal in the correct anatomical position, or structures do not heal properly, the person is more susceptible to recurrent dislocations and further damage

Atraumatic:

From chronic recurrent use, causing change in mobility of the shoulder

Congenital - secondary to hypermobility syndrome or ehlers-danlos syndrome - affects connective tissue structure causing laxity of static stabilisers in shoulder

Common in adolescent females with hypermobile joint

41
Q

Risk factors of Shoulder Instability

A

Previous dislocation = damage to static stabilisers - more likely to get recurrent dislocations because they have shoulder instability

42
Q

Types of Shoulder Instability

A

Anterior
Posterior
Inferior
Multidirectional - often caused by congenital conditions because they cause a general laxity in static stabilisers

43
Q

Classifications of shoulder instability

A

PRIMARY : Dislocation

T : traumatic

U : unidirectional instability - MOI: anterior most common (98%):ER+ABD; Posterior (2%)

B : Bankhart lesion - Capsular tear +/- detachment of labrum (labral tears common in throwing athletes); anteroinferior tear to labrum

S : Surgery

Apprehension in certain positions, decreased ROM into Abd + LR

SECONDARY : Poor neuromuscular control

A: atraumatic

M: multi-directional instabilty

B: bilateral

R: rehabilitation

I: inferior capsular shift

No history of injury

Excessive capsular / ligament laxity OR decreased neuromuscular control / muscle imbalance – may be related to posture / type of use

May predispose to impingement in young age group

Inferior instabilities are usually part of multidirectional instability

CONGENITAL

osseous/labral defect

Soft tissue abnormality

44
Q

Clinical Presentation of Shoulder Instability

A

General

Clicking / Pain

Positive apprehension test / relocation test (anterior) / load & shift test

Increased accessory motion at GHJ in the direction of instability; increased ROM compared to other limb

Positive sulcus sign

Age < 35

H/O shoulder feeling that it moves partly or completely ‘out of joint’ and may be concerned their shoulder may dislocate during certain activities or sports

If the instability is longstanding, there may be hand or arm weakness, tingling or numbness from proximal nerve traction

Primary (traumatic)

Pain around ant.lat. shoulder

Limited AROM

RHS rhythm

Positive apprehension test

Neural / vascular changes

Wasting of deltoid/rotator cuff

Secondary (atraumatic)

Full or excessive ROM

Pain at EOR on movement

Clunking, sensation of ‘coming out’ of joint

Dead arm on overhead activities – particularly with anterior instabilities

Loose / empty end feel on passive testing

Positive stress tests - sulcus test, anterior aprehension test, load & shift tests

45
Q

Medical management of Shoulder Instability

A

Surgery – depending on structural impairments, i.e. labral tears
Physio takes a post-op role after a period of immobilisation (4 weeks)

46
Q

Physiotherapy management of shoulder instability

A

primarily focused on training dynamic stabilisers

Neuromuscular retraining +++

Stretching / mobilisation tight capsule / rotator cuff

Other structures may require stretching, i.e. pectoralis majors shortened = pulling shoulder anteriorly

Postural re-ed

Strength Training - of deltoid - plays stabilising role in GHJ

Proprioception Training

47
Q

Define Acromioclavicular joint injuries

A

Acromioclavicular joint injuries can involve stretching or tearing of the acromioclavicular or coracoclavicular ligaments and subluxation or dislocation of the acromioclavicular joint

48
Q

Aetiology of Acromioclavicular injuries

A

Most commonly occur in men aged 20-50 years

MOI: a fall onto the point of the shoulder during sporting activity or FOOSH

Grade I: Intact joint with minor tear of the acromioclavicular ligaments.

Grade II: Up to 50% vertical subluxation of the clavicle with rupture of the acromioclavicular ligament and stretching of the coracoclavicular ligaments.

Grade III: more than 50% vertical subluxation of the clavicle with complete rupture of both acromioclavicular and coracoclavicular ligaments

49
Q

Clinical features of an acromioclavicular subluxation/dislocation

A

tenderness localised to the AC joint, limited range of movement due to pain, high arc pain or a positive cross arm test

Step deformity, TOP - increased clavicle angle to acromion

Decreased HF / elevation. above 90º

50
Q

Management of acromioclavicular subluxations/dislocations

A

Conservative:

POLICE +

Mobilisation - if stiffer

Active exs

Surgical:

A/C joint stabilisation using coracohumeral ligament

Surgical management of A/C joint only in cases where there is continuing pain or disability or failure of conservative treatment 3 months post injury

Patho 2 (30 decks)

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