SHOULDER PROBLEMS Flashcards
SHOULDER: injuries: %, sports, % of persistent symtpoms
- 7% to 34% of population develops shoulder problems
- One of most affected body region in many sports such as: handball, baseball, swimming & volleyball (overhead athletes)
- 54% of patients with shoulder problems report persistent symptoms after 3years
SHOULDER GIRDLE COMPLEX: ≠ considerations, natural stabilizers & dynamic stabilizers
≠ considerations:
- Anatomical = nb & type of articulations
- Morphological = shape & size of acromion - Kinematics = quantity of mvt
- Kinetics = joint torque
- Functional = quality of mvt
High mobility + low stability => injury
Natural (static) stabilizers
- GH, AC & SC
- Ligaments
- Joint capsular
- Labrum
Dynamic stabilizers
- ≠ muscle tendon units provide stability to GH articulation
- Important role in centering humeral head in glenoid
COMMON MSK SHOULDER INJURIES: ≠ patho
- Shoulder impingement syndrome
- Rotator cuff (RC) pathology (tendinopathy & tears)
- Scapular dyskinesis
- GH instability, including labral tears (SLAP & Bankart injury)
- Biceps long head tendinopathy
- Posterior shoulder stiffness (GIRD)
- Acromio & sternoclavicular pathology
- Adhesive capsulitis – arthrofibrosis
ROTATOR CUFF TENDINOPATHY : intrinsic mechanisms, extrinsic mechanisms, clinical presentation
Rotator cuff tendinopathy
Intrinsic mechanisms (within tendon)
- Overuse injury
- Degeneration of tendon fibers (tendinosis) as main cause
- Role of inflammatory process not clear (absence of inflammatory cells in patients with RC pathology)
- Changes in tendon structure – fibrocartilage formation close to tendon insertion
- Structural & mechanical inability to deal with compressive & tensile forces – tendon failure & rupture
=> secondary, external impingement
Extrinsic mechanisms (outside tendon)
- Anatomical Variables (acromial shape)
- Overuse injury
- Internal & external impingement as forms of compression
- Superior translation of humeral head (weak infraspinatus & teres minor)
- Involvement of coracoacromial ligament
Clinical presentation
- Pain during overhead activities (throwing)
- Movements below 90° of shoulder abduction usualy pain-free
- Tenderness during palpation of supraspinatus tendon & infraspinatus (if involved)
- Painful arc present
- Impingement tests & aprehension positive
- Tears usually confirmed with imaging exams (ultrasound)
- In patients > age of 60, with weak external rotators, weak supraspinatus & impingement signs => 98% chance of having rotator cuff tear
ROTATOR CUFF TEARS: clinical presentation
Clinical presentation
- Pain radiating to lateral mid-humerus or anterolateral acromion, pain while lying on shoulder or sleeping with arm overhead, & pain occurring when reaching above head
ACROMIOCLAVICULAR SPRAIN: def & characteristics
- Traumatic injury, affecting mainly capsula, & ligaments, but also muscles, skin & fascia
- 6 categories from slightest to greatest injury
- Conservative treatment in less severe categories (I, II & possibly III)
BICEPS TENDINOPATHY: def & characteristics
- Occurs primarily in long head
- Result of shoulder instability, impingement, rotator pathology or overuse of shoulder
- Patient reports tenderness in bicipital groove, night pain & pain at rest
SHOULDER IMPINGEMENT SYNDROME: def, internal impingement & external impingement
- Most common shoulder complain, representing up to 65% of all shoulder problems
- Impingement of RC muscles between bone structures - Common complaints of pain in shoulder abduction or flexion, side lying
Internal impingement
- Glenoid impingement
- Very frequent in overhead athletes, caused by repetitive motions involving large shoulder external rotation
- Impingement between SS & IF tendons, greater tubercle postero-superior rim of glenoid
- Hyperangulation of humerus in relation to scapula
External impingement (subacromial)
- Classified in primary & secondary
- Structural obstructions
- Functional problems:
* Rotator cuff weakness
* Instability
* Scapular dyskinesis
* Biceps pathology
=> all cause instability of humeral head, affecting shoulder kinematics & leading to impingement
ADHESIVE CAPSULITIS = Frozen shoulder: def , etiology, 2nd type & characteristics
- Arthrofibrosis
- Idiopathic frozen shoulder occurs spontaneously, usually over 35 years old , affecting more women
- Secondary adhesive capsulitis occur after surgery, immobilization, prolonged inflammation of tendons
- Capsular pattern: motion loss in ER > ABD > FL > IR
- Rehabilitation of adhesive capsulitis can be prolonged process
- Usually patients don t́ recover full ROM
GLENOHUMERAL INSTABILITY: ≠ types + def & characteristics of each + SLAP
- traumatic
- acquired
- atraumatic
TRAUMATIC INSTABILITY
- Result of direct contact, leading to anterior dislocation of humerus
- Often associated to Bankart & Hill-Sachs lesions (requires surgery) - On observation => prominent humeral head & space below acromion
ACQUIRED INSTABILITY
- Typically result of overuse mechanisms
- Acquired instability due to hyperangulation
- Sometimes associated to subluxations of humeral head
- Dead arm syndrome
- Frequently results in internal or external impingement, leading to RC pathology
- Often associated to scapular dyskinesis, GIRD, or SLAP lesion
Sup labral anterior to posterior (SLAP) injury
Excessive traction of biceps tendon:
- Eccentric follow-through of long head of biceps tendon after throwing - Peel-back mechanism during extreme ER
- 4 types of SLAP injury
ATRAUMATIC INSTABILITY
- Multidirectional (anterior, posterior, inferior) type of instability
- Normally result of ligament hyperlaxity
- Due to repetitive trauma
- Pain normally occurs in mid ROM, indication of altered muscle activity
GLENOHUMERAL INTERNAL ROTATION DEFICIT: GIRD: def & characteristics
- Occurs primarily in overhead athletes & caused by repetitive throwing
- Tightening of posterior capsule or posteroinferior capsule leads to increased anterior translation of humeral head (capsular constraint mechanism)
- Decreased subacromial space – related to both forms of shoulder impingement
SCAPULAR DYSKINESIS: def, causes, force-couples, lack of soft tissue flexibility, lack of muscle performance, clinical presentation
D: - Defined as altered scapular motion & position
- Usually involves lack of scapula upward rotation, posterior tilt & external rotation
C: * Bone causes (thoracic kyphosis or clavicle fracture mal-union)
* Articular causes (AC or GH instability),
* Soft tissue causes (muscle tightness & weakness, posterior GH capsula stiffness)
Force-couples:
- UT, LT & SA for upward rotation
- SA & LT for posteriorly tilt
- SA & MT for external rotation
Lack of soft tissue flexibility
Tightness of posterior capsula & pectoralis minor linked to altered scapular kinematics (increased scapular anterior tilt & protraction)
Lack of muscle performance
- Decrease strength of serratus anterior
- Hyperactivity & early activation of upper trapezius (shoulder shrug during arm elevation)
- Late activation of scapula stabilizers: middle & lower trapezius
Clinical presentation
- In resting position, excessive protraction, elevation & anterior tilt of scapula, reflected in observed signs:
* Winging of scapula
* Inferior & medial borders prominence
- During arm elevation:
* Early scapular elevation (shrug)
* Rapid downward rotation during arm lowering
- Scapular-humeral rhythm may be affected
