Shoulder pathology Flashcards
1
Q
What is the anatomy of a clavicle fracture?
A
- Sternoclavicular joint: Close packed position = Maximum shoulder elevation (synovial plane, gliding)
- Acromioclavicular joint: Synovial plane (gliding)
- Clavicle rotates posteriorly during GH abduction and flexion; restriction affects scapula movement
2
Q
What are the subjective findings of a clavicle fracture?
A
- Localised pain
- Pain and function reflective of healing stage
3
Q
What are the objective findings of a clavicle fracture?
A
- Observation: Protracted shoulder girdle
- Movement limitations: Difficulty with active protraction, retraction, elevation, depression, and GH flexion/abduction
4
Q
What is the treatment for a clavicle fracture?
A
- Common shoulder fracture (esp. in children)
- Sling immobilisation for 2-6 weeks
- Good prognosis: 90% of non-displaced fractures heal in 24 weeks
5
Q
What is the anatomy of an AC joint sprain?
A
- AC joint allows overhead and across-body movements
- Transmits force from arm to body in pushing, pulling, lifting
6
Q
What are the subjective findings of an AC joint sprain?
A
- Localised pain over the AC joint
- Aggravating factors:
- Heavy lifting
- Overhead movements
- Across-body movements
7
Q
What are the objective findings of an AC joint sprain?
A
- Observation: Swelling, bruising, possible hard lump at shoulder top
- Palpation: Specific tenderness over AC joint
- Movement limitations: Difficulty with GH flexion and horizontal adduction (cross-body test positive)
- positive scarf test
8
Q
What is the treatment for an AC joint sprain?
A
- Healing time: 6-8 weeks (ligament protection, possible sling)
- Physiotherapy goals:
- Restore ROM, muscle length, proprioception
- Minimise re-injury risk
- Return to sport/work in 8-12 weeks
9
Q
What is the anatomy of a GH joint dislocation?
A
- Restrictions: Concave glenoid, labrum, capsule, GH ligaments, long head of biceps, rotator cuff
Anterior dislocations associated with: - Labrum, middle/inferior GH ligament damage
- Rotator cuff tears
- Greater tuberosity fracture
10
Q
What are the subjective findings of a GH joint dislocation?
A
- Mechanism of injury
- Relocation details: When, who did it, and where
- Pre-existing shoulder instability
- Next clinic appointment
11
Q
What are the objective findings of a GH joint dislocation?
A
- Observation: Joint position and posture
- Active ROM (AROM): As comfortable
12
Q
What is the treatment for a GH joint dislocation?
A
- Immediate A&E referral and fracture clinic review
- Orthopaedic assessment & reduction
- Post-reduction management:
- Early mobilisation as pain allows
- Physiotherapy (4-12 weeks)
- Urgent ortho review if pain & weakness persist at 2-3 weeks (suspect rotator cuff tear)
13
Q
What is the anatomy of frozen shoulder?
A
- Frozen shoulder (adhesive capsulitis) is a painful condition caused by a contracture of the glenohumeral (GH) joint capsule, leading to stiffness and disability.
- It progresses through three stages: freezing, frozen, and thawing.
- It can occur idiopathically (gradual onset) or after trauma (less common).
- Most common in individuals aged 45-75, but can occur at any age.
- Patients experience pain in the deltoid region with increasing stiffness, making daily activities like putting on a coat, fastening a bra, applying deodorant, or changing gears difficult.
- Pain and stiffness depend on the stage of the condition.
14
Q
freezing stage
A
- Duration: 2-6 months
- Symptoms: Moderate to severe night pain, partial ROM loss
- Pathology: Widespread joint inflammation causing increasing pain with minimal early ROM loss. Can mimic rotator cuff tendinopathy, but FS worsens over time
15
Q
Frozen stage
A
- Duration: 4-12 months
- Symptoms: This stage is characterized by both pain and stiffness, with more pain in the early part of the stage and more stiffness as it progresses.
- Pathology: Inflammation decreases, and widespread fibrosis develops in the joint capsule and ligaments, causing significant restriction in ROM.
16
Q
Thawing Stage
A
- Duration: 6-26 months
- Symptoms: The pain significantly decreases, and there is a gradual improvement in stiffness.
- Pathology: Inflammation and fibrosis resolve, leading to minimal pain and a progressive return of movement.
17
Q
Risk Factors for Frozen Shoulder
A
Diabetes: 33% higher lifetime risk
Thyroid Disease
Hypothyroidism: 92% higher risk (
Gender: Women more likley
Age: Most common in 40-60 years, rare before 40
18
Q
frozen shoulder Advise on activity modification and pain control.
A
- When the shoulder is painful, continue to use the arm to maintain movement and ease spasm. Avoid movements which worsen the pain. This may require time off work or away from leisure activities.
- Take analgesia as advised.
- Hot packs may be helpful.
- In bed, support the arm with pillows (to prevent rolling onto the affected shoulder).
19
Q
What are the objective findings of frozen shoulder?
A
- Capsular pattern restriction: most limited in external rotation, followed by abduction, least limited in flexion.
- If passive external rotation is full, it’s not frozen shoulder.
- If passive ER full and painless –> no capsular involvement
- Positive impingement tests may be seen.
- Reduced accessory movements due to restricted humeral head glide–> opposite to angular movement
20
Q
What is the treatment for frozen shoulder?
A
- Natural resolution (~2 years)
- Treatment speeds recovery & reduces impact
- No need for aggressive home stretching—use shoulder normally
Treatment per stage:
- Stage I & II: Injection, pain relief (TENS, NSAIDs, mobilisations), active movements- pendulums
- Stage III: Time, mobilisations/manipulations (short-term relief, may increase long-term soreness)
- Stage IV: No treatment usually needed, possible ROM/strengthening exercises
21
Q
What are the subjective findings of frozen shoulder
A
Idiopathic (gradual onset) pain & stiffness
- Can be secondary to trauma (less common)
- Common in 45-75-year-olds
- Pain in deltoid region
- Difficulty with:
- Doing up bra strap
- Applying deodorant
- Wearing a coat
- Changing car gears
- Pain patterns depend on stage
22
Q
Atraumatic instability pathophysiology
A
- Glenoid covers 25-30% humeral head= unstable joint
- Stability of GHJ depends upon fibrous tissue restraints and dynamic muscular action. Bony configuration provides little additional support
- Instability results from inefficiency of the coraco and glenohumeral Igts +/- rotator cuff.
- Scapular muscles esp serratus anterior and trapezius also contribute by way of scapular control
Not necessarily linked to a specific event but is often due to repetitive forces applied at a rate that exceeds that of tissue repair
23
Q
Atraumatic instability- types of instability
A
- Anterior
- Posterior
- Inferior (Multidirectional)
24
Q
Atraumatic instability- Movements to tighten posterior/anterior capsule of glenohumeral ligament
A
- Abduction and external rotation tighten the anterior portion of the IGHL
- Horizontal adduction and medial rotation tighten the posterior portion of the IGHL
25
Atraumatic instability- subjective
* onset (gradual vs sudden), “falls out” versus “pulled out”.
* Doesn’t feel right, not in place
* Feels like it needs to click
* PMH – connective tissue disorders (EDS, Marfans), hypermobility
* Dull ache
* Often do not c/o of instability, but more apprehension, a feeling something “not quite right”
* Fatigue; dead arm syndrome
* Pain at night whether lying on either side.
* If they do c/o shoulder “coming out” – does it come out all the way? How does it go back in? – disloc/sublux.
* Crucially, what position is the shoulder when pt experiences Sx? Nature of any instability
26
Atraumatic instability- objective
* Performing functional movements that reproduce symptoms
* Often instability tests are not required
* Normally full active range of motion and proprioception
* Muscle power: isometric test rotator cuff in different positions
* Assess whole kinetic chain eg squat, SLS, bridge
* Atrophy
* position humeral head
* ROM often full, but some pain end of flex/abd; weak cuff — possible tear;
* demonstrate instability?; generalized laxity?;
* +ve instability tests; possible +ve lag signs; possible biceps tear/tendinopathy; possible labral tear;
27
Atraumatic instability- treatment
* Conservative rehabilitation program
* Rotator cuff strengthening, proprioception, building speed and using the whole kinetic chain
* Psychological aspect to address any contributing factors, regain confidence and reduce fear
* Improve general activity
* Prognosis: Aim to return to activity and function
28
Atraumatic instability
Factors limiting anterior translation
Dynamic resistance
* Primary: posterior cuff (infraspinatus + teres minor)
* Secondary: long head of biceps (increase torsional rigidity); global cuff
Non-contractile resistance
* Primary: anterior band inferior GHL, ant band
* Secondary: coracohumeral Igt, superior GHL, middle, GHL, anterior capsule
29
Instability- Factors limiting posterior translation
Dynamic resistance
* Primary: anterior cuff (subscapularis)
* Secondary: global cuff
Non-contractile resistance
* Primary: posterior band inferior GHL
* Secondary: posterior capsule
30
Instability- Factors limiting inferior translation
Dynamic resistance
* Primary: superior cuff (supraspinatus), global cuff
Non-contractile resistance
* Primary: dependent position – sup joint capsule + superior GHL, coracohumeral Igt + superior jt capsule >45deg abduction – inferior GHL
* Secondary: -ve intra-articular pressure
31
AC OA Joint Disease - Anatomy
* Osteoarthritis of the AC joint
* May have previously had AC joint sprain
* the cartilage covering the joint surfaces can gradually roughen and become thin. The bone underneath the cartilage then reacts by growing thicker and becoming broader, which can result in pain, swelling and restricted joint movement.
32
AC OA Joint Disease- Subjective
* Difficulty with activities above the head, washing hair, putting out washing
* Risk factors are those that do over head work – painters, plasters, weightlifters
* >60 years for OA
* 20-50 years for injuries to AC joint
33
AC OA Joint Disease- Objective
* Painful high arc on AROM
* Positive cross body arm test
* Tender on palpation of AC joint
34
AC OA Joint Disease- Treatment:
* Activity modification (avoid cross over and heavy lifting), analgesia, referral to physio
* Physio – management of symptoms
35
Rotator Cuff Disorders / Subacromial impingement
Anatomy
Anatomy:
* Impingement syndrome of the shoulder refers to the symptoms of pain and dysfunction resulting from any pathology which either decreases the volume of the subacromial space or increases the size of its contents.
* Cant distinguish between what's being impinged on bursa or tendon so just say subacromial impingement
* Cause subacromial shoulder pain
* Includes rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis
* Can be termed shoulder impingement
Primary impingement
* acromial morphology; osteophytes; thickened cuff; calcific bursa/tendon; fracture; a-c dislocation; OA/RA; bony kyphosis/scoliosis.(PT cant do anything about primary- can get injections tho)
Secondary impingement
* posture; weakness; instability; ergonomics; neuropathy; muscle imbalance
Primary inflammation/degenerative changes
* tendinitis/osis; bursitis; synovitis; capsulitis; cuff tears; ageing
36
Rotator Cuff Disorders / Subacromial impingement
Subjective:
Can describe:
* “Catches me out”, pain on lifting eg kettle, or activities with arm above head. May describe a painful arc.
Onset:
* May occur gradually or after a change in activity/loading – sport, occupation, recent life change (moved house) or training
Sleep:
* May have night pain due to difficulty laying on shoulder
History:
* v common in >45yrs
* usually gradual onset with a Hx of overuse or unaccustomed use involving repetitive actions in abd/flex posn eg gardening, DIY, moving house; pain on reaching/lifting, putting on coat,
* lying on affected side
* if severe, pain can spread down arm to hand.
* If sudden onset, may indicate tear; weakness;
* struggling to sleep
* may have pain in morning due to enthesopathy –
o Inflammation: Overnight, when the body is at rest, inflammatory chemicals can accumulate in the affected areas, leading to stiffness and discomfort upon waking.
o Reduced Blood Flow: Immobility during sleep can reduce circulation, causing stiffness in affected tendons and ligaments.
o Lack of Lubrication: Synovial fluid, which helps reduce friction, thickens during rest and needs movement to redistribute.
37
Rotator Cuff Disorders / Subacromial impingement
Objective
* Painful arc of abduction (in scapula plane) – pain between 70-120 degrees
* Pain worse if thumb down and against resistance
* Isometric muscle testing – belly press +/- lift off sign for subscapularis
* Special tests – Hawkins & Kennedy and Neer
Exam:
* painful flex/abd, but full passive movt
* weak cuff — pain inhibition or possible tear?
* +ve impingement tests; possible +ve lag signs
38
Rotator cuff test limitation
* You can’t tell what part of the rotator cuff is injured due to pain from clinical tests as the cuff works together. Would label it subacromial impingement unless there is a massive tear as you won’t have pain you'll have global weakness of a certain movement actioned by a specific dominant muscle
39
Rotator Cuff Disorders / Subacromial impingement
Treatment
* Selective rest
* Rehabilitation — must be rational, appropriate and progressive; scap muscles before cuff. Also include correction of faulty technique/posture
* Eccentric loading is good for enthesopathy’s
* Injection — no unanimity re route, drug, dosage, technique, asepsis, post-inj protocol
* Surgery — subacromial decompression; cuff repair
40
5 principles of treatment
1. Establish cortical potential for normal movement. (Control the pain)
2. Establish mechanical potential for normal movement. (Restore full passive movt)
3. Establish muscular potential for normal movement. (Restore strength)
4. Establish normal movement. (Eradicate trick movts/unlearn bad habits)
5. Re-enforce normal movement. (Practice)
