Shoulder Pathologies Flashcards
Common pathologies affecting the shoulder
Primary Shoulder Impingement
Split into: external (primary and secondary), and internal (posterosuperior and anterosperior)
External Shoulder Impingement
Primary: impingement associated with coracoacromial arch
Secondary: impingement due to abnormal glenohumeral and scapulothoracic movement
Internal Shoulder Impingement
Posterosuperior: impingement between the glenohumeral head and glenoid in the ABER position
Anterosuperios: impingement between the humeral head and glenoid in the ABIR position
Signs and Symptoms of Impingement
- Painful arc
- Pain on the superolateral aspect of the arm
- Pain or aching at night
- Gradual onset/over-use
- Weakness in arm
Primary External Impingement
superior structures are abnormal; causing compression of the subacromial space from above.
Usually the acromion is/has become beaked, curved or hooked.
In older age groups, other abnormalities may occur (e.g. osteophyte formation on the ACJ or a thickening of the coracoacromial arch.
Secondary External Impingements
Caused by joint kinematics rather than structural changes; the muscles attached to the medial border of the scapula have become weakened and fail to control protraction and retraction; causing a narrowing of the subacromical space.
Usually coupled with tight pectoral muscles.
Rotator cuff tendons may be weakened due to excessive load; resulting in superior translation of the humeral head when the deltoids contract
Internal Impingement
Occurs most commonly in overhead athletes and is caused by repetitive or excessive contact between the posterior aspect of the humeral head and the posterior superior aspect of the glenoid border.
Most common painful position will be extension, abduction and external rotation.
This position may compress the supraspinatus or infraspinatus tendons and over time will cause pain.
Adhesive Capsulitis
Common condition characterised by progressive pain and limited ROM of the GHJ.
Categorised into 4 stages.
Cause is poorly understood, thought to be related to capsular fibrosis.
Can occur after a period of time where the shoulder has been immobilised.
Most identifiable symptoms are pain and loss of range, both with gradual onset.
Imaging required to determine exact stage
Stages of Adhesive Capsulitis
Pre-Freezing: 0-3 months - pain and limited RoM
Freezing: 3-9 months - severely restricted RoM and pain
Frozen: 9-15 months - severe stiffness and minimal pain
Thawing: 15-24 months - improvement in RoM and minimal pain
SLAP Lesions
Superior Labrum Anterior to Posterior tears. Can be acute or chronic and account for unto 8% of shoulder injuries.
Athletes who play sports involving overhead actions are most prone.
SLAP Lesions Symptoms
Deep pain in the shoulder
Pain when recreating over-head actions
Popping and grinding
Athletes may not be able to perform overhead actions to same ability
Rotator Cuff Tendinopathy
Presents with impingement symptoms and is a common cause of shoulder pain in athletes.
Caused by tendons becoming inflamed and weakened due to collagen matrix being disorganised.
Athletes with a tendinopathy will complain of pain with overhead activity.
Activities requiring less than 90 degrees of abduction will usually be pain free
Rotator Cuff Strain
Insidious onset
Minor to moderate strains: some limitation of function and responds well to a period of off-loading
Moderate to severe strains (ruptures): loss of function and pain preventing them from sleeping on affected side
Full thickness tears: require surgical management, particularly in younger athletes
Acromioclavicular Joint Injury
Common injury in sports where athlete can fall directly onto the joint or receive a blow to the lateral aspect of the shoulder.
Clinically, ACJ will be visibly deformed with localised pain on palpation. If not seen acutely, RoM may not be directly affected but the patient may report feeling stiff in their shoulder.
Rockwood Classification used to describe six different types of ACJ injuries
Rockwood Classification
Grades 1&2: conservative management with a similar protocol to other ligament injuries should be followed
Grade 3: argument around this; consensus is conservative management first then followed by surgery if not effective
Grades 4-6: surgical repair required
Rockwood Type 1
Pathology: sprained AC ligaments; normal CC ligaments
Examination: pain and swelling over the ACJ without a visible deformity
Radiography: normal
Rockwood Type 2
Pathology: disruption of AC ligaments; sprained CC ligaments
Examination: distal clavicle unstable to horizontal stress; pain over the CC interspace
Radiography: widened ACJ and slight elevation of the clavicle (<25%)
Rockwood Type 3
Pathology: disruption of AC and CC ligaments
Examination: distal clavicle unstable to horizontal and vertical stress; reducible
Radiography: moderate elevation of the clavicle (25%-100%)
Rockwood Type 4
Pathology: posterior displacement into or through the trapezius
Examination: not reducible
Radiography: axillary view shows posterior displacement
Rockwood Type 5
Pathology: rupture of the deltotrapezial fascia
Examination: clavicle palpable subcutaneously; not reducible
Radiography: distal clavicle elevated (>100% - 300%)
Rockwood Type 6
Pathology: inferior displacement of the distal clavicle under the conjoined tendon
Examination: associated with rib fractures and neuromuscular injury
Radiography: clavicle in a subacromial or subcoroacoid position
Anterior Dislocation
Mechanism of injury is excessive external rotation in an abducted position or a fall onto an outstretched arm.
GHJ will have characteristic appearance where the humeral head is positioned inferiorly to where it should be and a loss of ROM
May be damage to axillary nerve; loss in sensation or neural symptoms
Do not try to reposition shoulder unless blood supply disrupted.
High occurrence in young athletes and may require surgical repair if instability is detected
Differential Diagnoses
- Bicep tendinopathy
- Pec Major muscle injuries
- Posterior shoulder dislocation
- GHJ sublucations
- Other labral tears
- Fractures of humerus and clavicle
