Shoulder Pathologies

Question 1

Common Tendinopathy in UL

Answer 1

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

Question 2

Define Rotator Cuff Shoulder Related Pain (RCRSP)

Answer 2

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

Question 3

Pathogenesis of rotator cuff tendinopathy

Answer 3

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

Question 4

Risk factors of rotator cuff shoulder related pain

Answer 4

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

Question 5

Clinical presentation of rotator cuff shoulder related pain

Answer 5

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

Question 6

Management of RCSRP

Answer 6

○ 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

Question 7

Define Adhesive Capsulitis (frozen shoulder)

Answer 7

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

Question 8

Prevalence of frozen shoulder

Answer 8

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

Question 9

Types of Frozen Shoulder

Answer 9

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

Question 10

Risk factors of Frozen Shoulder

Answer 10

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

Question 11

Stage 1/3 of Frozen Shoulder Pathology

Answer 11

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

Question 12

Stage 2/3 of Frozen Shoulder Pathology

Answer 12

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

Question 13

Stage 3 of Frozen Shoulder Pathology

Answer 13

Recovery (Thawing) Phase (12-42 months)

Gradual improvement in range of movement with less stiffness

Question 14

Clinical presentation of Frozen Shoulder

Answer 14

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

Question 15

Medical management of Frozen Shoulder

Answer 15

• 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)

Question 16

Physiotherapy management of Frozen Shoulder

Answer 16

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

Question 17

Prevalence of Clavicle #

Answer 17

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 #)

Question 18

Medical management of clavicle #

Answer 18

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

Question 19

Physiotherapy management of clavicle #

Answer 19

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

Question 20

Prevalence of proximal humerus #

Answer 20

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

Question 21

Management of proximal humerus #

Answer 21

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

Question 22

Prevalence of OA

Answer 22

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

Question 23

Medical management of OA

Answer 23

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

Question 24

Physiotherapy management of OA

Answer 24

§ 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

Question 25

Define Rheumatoid Arthritis (RA)

Answer 25

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

Question 26

Pathology of RA

Answer 26

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

Question 27

Prevalence of RA

Answer 27

○ 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

Question 28

Risk factors of RA

Answer 28

Genetic Factors (non-modifiable) Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D

Question 29

Clinical Presentation of RA

Answer 29

○ 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

Question 30

Medical management of RA

Answer 30

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

Question 31

Physiotherapy management of RA

Answer 31

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

Question 32

Define shoulder dislocation

Answer 32

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

Question 33

What are the static and dynamic shoulder stabilisers

Answer 33

**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

Question 34

Pathology of Anterior Shoulder Dislocation

Answer 34

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

Question 35

Prevalence of Anterior Shoulder Dislocation

Answer 35

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

Question 36

What lesions can an Anterior Shoulder Dislocation result in

Answer 36

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"

Question 37

Prevalence of Posterior Shoulder Dislocation

Answer 37

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

Question 38

Prognosis of shoulder dislocations

Answer 38

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

Question 39

Define Shoulder Instability

Answer 39

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

Question 40

Causes of Shoulder Instability

Answer 40

**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

Question 41

Risk factors of Shoulder Instability

Answer 41

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

Question 42

Types of Shoulder Instability

Answer 42

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

Question 43

Classifications of shoulder instability

Answer 43

**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

Question 44

Clinical Presentation of Shoulder Instability

Answer 44

**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

Question 45

Medical management of Shoulder Instability

Answer 45

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

Question 46

Physiotherapy management of shoulder instability

Answer 46

**primarily focused on training dynamic stabilisers** ## Footnote 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

Question 47

Define Acromioclavicular joint injuries

Answer 47

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

Question 48

Aetiology of Acromioclavicular injuries

Answer 48

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

Question 49

Clinical features of an acromioclavicular subluxation/dislocation

Answer 49

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

Question 50

Management of acromioclavicular subluxations/dislocations

Answer 50

**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