shoulder soft tissue injuries Flashcards
what kind of joint is the shoulder joint?
a synovial ball and socket
what % of the humeral head is in contact with the glenoid fossa at any time?
25-35%
what are the static stabilisers of the shoulder joint?
-labrum
-glenohumeral ligaments
what are the dynamic stabilisers of the shoulder?
-rotator cuff muscles
-deltoid muscle
how much synovial fluid does a normal shoulder joint hold?
10-30 mls
what are the attachments of the shoulder joint capsule?
-around the margins of the labrum proximally
-around the anatomical neck of humerus distally
-attaches a fingers breath below the surgical neck
what is the shoulder joint capsule re-inforced by?
-ligaments - superior, middle and inferior GH ligaments and the coraco-humeral ligament
-Rc muscles
-long head of biceps gives anterior support
what can occur if the inferior GH ligament is torn?
multidirectional instability
what is the function of the glenoid labrum?
deepens the socket to increase stability
what part of the labrum is most vulnerable to injury as a result of anterior dislocation?
@ 2 o clock - there is a fold of synovial membrane - most vulnerable part
what is the matsen classification?
divides shoulder instability events into the traumatic, unidirectional, Bankart lesion, and surgery (TUBS) and AMBRI classification
what does TUBS stand for- ie what are the types of recurrent shoulder instability?
-traumatic aetiology
-unidirectional instability
-bankart lesion
-surgery required
what does AMBRI stand for in terms of shoulder instability?
-atraumatic
-multidirectional instability may be present
-bilateral
-rehabilitation is the treatment of choice
-inferior capsular shift -surgery required if conservative treatment fails
according to matsen what are the 2 ways to classify shoulder instability?
- TUBS
-AMBRI
what is laxity in relation to a joint
laxity refers to the degree of looseness or instability in a joint
what is the stanmore triangle classification of shoulder instability?
-Stanmore classification system proposes three types of shoulder instability
-It looks at both the things that are part of the shoulder’s structure and those that are not. It also says that there’s a range of issues that can happen, not just one specific problem
what are the 3 types of instabilities according to the Stanmore triangle?
-polar type I
-polar type II
-polar type III
Describe polar type I
-these patients usually present with a positive apprehension test in an anterior direction
-traumatic injury -TUBS
-may have RC weakness
Describe polar type Ii
-Patients in this group present with positive anterior apprehension test with signs of increased capsular laxity, excessive external rotation
-atraumatic - AMBRI
Describe polar type III
patients in this group show suppression of rotator cuff muscles, abnormal muscle patterning - ie delta and pecs compensate for mvt
in what direction does dislocation of the shoulder joint occur most often?
anterior direction
then inferior
what are examples of tests that test for anterior instability?
-apprehension test
-apprehension relocation test
what is an example of a test that examines posterior instability?
the jerk test
what is an example of a test that examines inferior instability?
sulcus sign
what test examines multidirectional instability?
rowe test
how is shoulder instability defined?
-pathological increase in translators mvt that interfere with joint mvt and produce pain
what factors is should instability classified on?
-severity- ie subluxation or dislocation
-duration - acute or chronic
-occurence - single of recurrent
-mechanism - traumatic or non-traumatic
-direction - anterior/inferior / posterior/multidirectional
what might the patient history include with an anterior Glenohumeral dislocation?
-trauma -forced into excessive abduction & ER, or direct trauma onto humeral head
-pain NB
-they may report a feeling of the shoulder ‘popping out’
-report loss of function
upon examination, what might a physio observe in a patient with an anterior shoulder dislocation?
-loss of AROM and PROM
-positive apprehension test
what does the apprehension test involve?
-physio externally rotates shoulder with elbow flexed to 90 degrees in an abducted position
-patient will feel extreme pain and discomfort and express apprehension
what does the apprehension relocation test involve?
-physio abducts and externally rotates the shoulder and pushes the head of the humerus from anterior to posterior
-if this relocates or relieves the patients discomfort, they have a GH joint that has subluxed anteriorly
what does the management of an acute shoulder dislocation involve - initially, 2 weeks and 6 weeks post op?
- x ray to rule out fracture
-rest in sling for 2 weeks
2 weeks post: scapular strengthening exercises and active range of motion exercises (but avoid positions w/ abduction and ER)
6 weeks post op: gradual restoration of ROM & strength, continue scapular strengthening and RC strengthening etc
what is the recurrence rate of an acute anterior shoulder dislocation?
-17-96% - mean of 67%
in what positions does anterior shoulder instability occur?
-abduction
-lateral rotation
compare traumatic vs atraumatic anterior shoulder instability
-traumatic - following an acute episode of anterior shoulder dislocation
-atraumatic - as a result of repetitive stressing of external rotatory mvts eg swimmers & tennis players
describe posterior shoulder instability
traumatic
falling with arm in flexion/ adduction and internal rotation
seen in people who have seizures eg epilepsy - therefore NB subjective
what does the jerk test involve?
-stabilising the scapula with one hand, while the other hand holds the elbow w/ the arm in 90 degree abduction and IR and firm compression is applied to the shoulder joint
-arm is then horizontally adducted while maintaining the firm axial load
what are the signs of a positive jerk test?
-sudden jerk or clunk as the head of hummus moves back off the back of the glenoid
describe the management of a posterior dislocation
-reduction, immobilise in ER
-avoid horizontal flexion and IR for 6 weeks
-strengthening the posterior cuff muscles
-may be associated with posterior labrum tear which may need surgical repair
what are the clinical features of multi-directional shoulder instability?
-increase in joint volume - ie hypermobiity
-enlarged joint capsule
-lax and thin glenohumeral ligaments
-generalised laxity throughout the body
-positive instability ests
how is multidirectional instability managed - conservative and surgically ?
-physio - strengthening of rotator cuff and scapular stabilisers and proprioception retraining
-surgical - capsular shift - aims to tighten the ligaments and decreases the size of the shoulder capsule or a glenoid osteoplasty
what happens when there is a glenoid labrum tear?
-joint looses the negative pressure mechanism as the labrum creates a suction seal on capsule
-increase in mvt esp in anterior direction
what is a SLAP labrum tear?
-superior labrum anterior to posterior
- involves the attachment site of the biceps tendon located at the top of the shoulder joint.
what does the patient usually report with a SLAP lesion?
-clicking sounds
-locking of the shoulder
-a feeling that the shoulder doesnt feel right
what is a Bankart lesion of the labrum?
-injury to the anterior inferior part of the labrum
-involves the inferior Glenohumeral ligament
-humeral head shifts towards the front of the body
what are examples of clinical features of a SLAP or Bankart lesion?
-vague pain with overhead activities eg throwing or hitting
-pain in posterior/lateral shoulder
-mechanical symptoms of catching, locking, grinding etc
-pain while lying on shoulder
-decreased ROM
-loss of strength
describe MOI’s for a slap lesion
-traction / compression injuries
1. traction - sudden pull downwards - one loses hold of a heavy object
-pull of arm in upward direction -grabbing an overhead object
-forward pull of arm - eg water skiing
-overhead throwing
2. compression
-fall onto outstretched arm
-direct blow to shoulder
Explain the 4 types of SLAP lesion
-type 1 - degenerative & attachment of LHB to labrum is stable
-type 2 - damaged/frayed - attachment of LHB is unstable
- type 3- bucket handle tear of superior labrum, but doesn’t extend to LHB tendon but attachment is unstable
-type 4- bucket handle tear of superior labrum extending to the LHB tendon
what are examples of tests that can be done to see if a labral tear is present?
-biceps load test
-O’Briens active compression test
-crank test
what are the physio aims with a labral tear?
-reduce pain
-restore ROM
-stabilise joint via rotator cuff strengthening
-post surgical rehab
-functional re-education to facilitate return to work and normal activity
what are other terms to describe frozen shoulder?
adhesive capsulitis
contracted shoulder
what are important clinical features of a ‘frozen’ shoulder?
-pain is greater than stiffness or stiffness is greater than pain
-limited or blocked rotation NB
-loss of AROM=PROM
-must be accompanied by normal radiographic finding’s
what characteristics is a frozen shoulder commonly associated with?
-female gender
-40-60 years
-trauma
-diabetes - due to cell changes
-thyroid disease - due to cell changes
-prolonged immobilisation
-post op
what are the principles of management of a frozen shoulder?
-advice and education - easy to understand explanation to the patient about their condition
-reduce pain - relative rest avoiding aggravating activities and doing exercises in pain free ROM
-correct joint and ST mobility - maximise joint mobility ROM exercises
-local and global muscle control strength, endurance and proprioception
-re education to facilitate return to work
Describe shoulder OA
- 3rd most common joint to be affected by OA
-cartilage covering joint surfaces becomes thin and roughens up
-the bone underneath the cartilage reacts by growing thicker and becoming broader
-pain , swelling and reduced ROM
describe OA of the AC joint
- degeneration of the AC joint
-joint space narrows due to inflammation or formation of osteophytes which can aggravate the subacromial bursa and decrease ROM
-ache into the deltoid region
