UE Disorders Flashcards
3 bones that make up the shoulder?
- Humerus
- Clavicle
- Scapula
4 Articulations of the shoulder?
- Glenohumeral (GH)
- ball & socket joint
- bulk of the motion occurs here
- 2/3 of the shoulder motion comes from GH joint
- Scapulothoracic
- elevates the arm
- 1/3 of the shoulder motion comes from this
- Acromioclavicular Joint (AC joint)
- articulation of the acromion process & distal clavicle
- little or no motion
- Sternoclavicular Joint (SC joint)
- proximal clavicle articulates with sternum
- little or no motion
Rotator Cuff Muscles and Functions?
Rotator cuff muscles make up the intrinsic muscles of the shoulder Tendons come together & form a common tendon that is important in shoulder stability Supraspinatus is the most superior muscle & most susceptible to injury Subscapularis is the anterior muscle of the cuff & acts as an internal rotator Infraspinatus is a posterior muscle & acts as an external rotator Teres Minor (posterior) & acts as external rotators
Extrinsic Muscles of the Shoulder include?
- Deltoid
- Pectoralis major
- Latissimus dorsi
- Teres major
Function to move the humerus
Bicep muscle function
Acts as both an intrinsic & extrinsic muscle
Intrinsic function is to stabilize the GH joint
Extrinsic function flexes the elbow
Important in throwing & overhead motion
Patients < 40 y/o with glenohumeral instability are more likely due to?
to labral injuries (dislocations & SLAP tears), chondral injuries, AC separation, stress fx, & fx secondary to high energy impact & trauma
Patients > 40 y/o with glenohumeral instability are more likely due to
calcific tendinitis, fractures, AC & GH osteoarthritis, frozen shoulder, rotator cuff tendinitis, impingement, & rotator cuff tear
Focal pain on top of the shoulder suggests what?
AC joint involvement
5 Peripheral nerves that can be injured and affect shoulder function
Axillary Nerve (C5-6) Suprascapular Nerve (C5-6) Musculocutaneous Nerve (C5-6) Long Thoracic Nerve (C5-8) Spinal Accessory Nerve
Axillary nerve affects what?
Most commonly injured
Occurs most commonly with anterior dislocation
Can also be injured with brachial plexus injury or compression or during shoulder surgery
Affects deltoid function
- weakness results in inability to abduct
Affects Teres minor function
- weakness results in decreased external rotation, but
can be compensated for & not easily recognized
Sensory loss over the deltoid most profound in a 2-3 cm area over the deltoid insertion
No DTR’s are affected
Suprascapular nerve injury?
Can be injured with a fall on the posterior shoulder, stretch injury, or fractured scapula
Signs & symptoms mimic rotator cuff injury
History & mechanism of injury are important in distinguishing between the two
Seen in patients who do overhead throwing
Presents with posterior shoulder pain, weakness in shoulder abduction & external rotation
No DTR’s are affected
Musculocutaneous Nerve injury
Rarely injured
Usually from direct trauma with a humeral fx or along with a brachial plexus injury
Weakness in biceps & brachialis muscles resulting in weakness of elbow flexion
Sensory alteration on lateral aspect (thumb side) of the forearm
Biceps DTR is affected
Long Thoracic Nerve Injury?
Not very common
Usually occurs from repetitive microtrauma with heavy effort above shoulder height (shoveling, chopping, carrying a heavy backpack)
Weakness of the serratus anterior can result in scapular winging & difficulty with abduction > 90 degrees
No associated sensory or DTR abnormalities
Spinal Accessory Nerve Injury
Usually injured in the neck
Often injured due to poorly fitting backpack
Injury occurs distal to the cranial nerve & a portion of the sternoclidomastoid muscle is not affected
Trapezius muscle is affected
Shoulder shrug is diminished on the affected side
Difficulty with abduction > 90 degrees
No significant sensory disturbance except shoulder is aching
No DTR abnormalities
Rotator Cuff Tendonitis
Common complaint
Can occur at any age especially in those engaged in overhead activities
Results in edema & inflammation in the rotator cuff & sometimes micro tears
Thickening of the tendon with inflammation of overlying bursa
Clinical Presentation of Rotator Cuff Tendonitis
Pain in the shoulder radiates to the upper arm, but not past the elbow
Pain is worse with overhead activity including putting on a shirt & brushing hair
Pain may be localized to lateral deltoid area
Pain may be worse at night when lying on the affected shoulder
Treatment of Rotator Cuff Tendonitis
Rest – avoid all provocative activities
Sling is not encouraged as it may cause more stiffness
Gentle ROM may be advanced to PT if needed when tolerable
Ice
NSAID’s
Patients who do not respond may require steroid injection
Modifications to work or activity may be required to avoid chronic inflammation
Most improve in 4-6 weeks
Calcific Tendonitis
Presentation is often similar to the patient with tendinitis, but patient often notes more pain with ROM
Physical exam is similar to tendinitis, but often more pain with ROM & more palpable tenderness
Xray demonstrates calcium deposit as an increased area of density overlying the supraspinatus
Treatment of Calcific Tendonitis
Steroid injection is the treatment of choice
Calcific material often resorbs spontaneously
In severe cases subacromial decompression arthroscopic surgery & needling of the calcific deposit is required
Impingement Syndrome
Most common cause of shoulder pain
Attributable to the compression of structures around the GH joint that occur with shoulder elevation
Usually refers to problems with any of 3 soft tissue structures of the subacaromial (SA) space including the SA bursa, biceps tendon (long head), & the rotator cuff
Risk factors include repetitive activity at or above shoulder level during work or activities, instability of the GH joint, & scapular instability
Clinical Presentation of impingement syndrome
Similar to those with tendinitis including pain with overhead activity
The pain may localize to the deltoid area & often occurs while sleeping on the affected side
Throwing athletes c/o stiffness & pain in the posterior shoulder during the early acceleration or cocking phase
Serving athletes c/o pain with follow through or terminal wrist snap
Diagnostic Imaging for impingement syndrome?
Xray in the initial phase is only indicated with a traumatic injury, but is usually done to R/O any type of fx
MRI is performed if the symptoms & function fail to improve with conservative treatment, the dx remains unclear after initial evaluation, or there is a suspected rotator cuff or labrum tear
Stage 1 impingement syndrome
Stage 1
- edema & hemorrhage
- patients usually < 25 y/o
stage 2 impingement syndrome
Stage 2
- fibrosis & tendinitis
- patients generally 25 – 40 y/o
stage 3 impingement syndrome
Stage 3
- most common
- rotator cuff tear
- patients generally > 40 y/o
- patients have usually had at least one ocurrence of Stage 1 or Stage 2
Treatment for impingement syndrome
Initial management is similar to tendinitis including rest (avoid provocative movements), ice, & 7-10 day course of NSAID’s
PT may also be included to regain strength & ROM
Steroid injections may provide symptomatic relief & improve the patients effort & compliance with PT
Surgical subacromial decompression is the definitive treatment as it opens the space & gives direct visualization to the rotator cuff
Acute Traumatic Tears of Rotator Cuff
- result from a fall on an outstretched hand or by
grabbing on while falling- pain is usually acute & referred to the deltoid
- significant pain when sleeping on the affected side
