UL MSK Pathologies Flashcards
Common Tendinopathy in UL
Rotator Cuff Related Pain Lateral Epicondylitis (Tennis elbow) Medial Epicondylitis (Golfer's elbow)
Define Rotator Cuff Shoulder Related Pain (RCRSP)
Most common tendinopathy of upper limb
Includes:
• Sub-acromial pain syndrome (Impingement) - bursitis
• Rotator Cuff Tendinopathy
• Rotator Cuff Tears - including long head biceps brachii tear
Pathogenesis of rotator cuff tendinopathy
Extrinsic factors:
- Mechanical irritation of contents of subacromial space compression between greater tubercle and upper part of glenoid causes superior slide of humeral head in glenoid
- Postural dysfunction - FHP, protracted shoulder girdle, kyphosis, scapula position; Leads to alteration of force couples operating around shoulder & faulty movements
- Muscle imbalances:
- Weak / fatigued / injured rotator cuff
- Results in loss of deltoid: RC force couple
- Allows superior migration of humeral head
- Leading to repetitive impingement of subacromial soft tissue
- Results in inflammation & rotator cuff disease
- Impingement of rotator cuff tendons secondary to G/H instability = Failure of static or dynamic stabilisers of GH joint allows excessive translation of HH
- Occupational / environmental / training: Anything that involves repetitive overhead manoeuvres eg. Tennis; painting ceiling; stacking shelves
Intrinsic Factors:
Degeneration of RC tendons
Deconditioned tendon - An under loaded tendon has no stimulus to build healthy tissue, will fail if suddenly over loaded
Joint side wear & tear
- Acromial side RC tendon fibres thicker & stronger
- Joint side fibres more vulnerable to tensile loads
- Lesions often found on joint side of tendon not acromial side
Risk factors of rotator cuff shoulder related pain
Age 35-75
H/O repetitive movements at or above shoulder height, or of heavy lifting
Athletes, workers who perform overhead activities and the elderly
Clinical presentation of rotator cuff shoulder related pain
Altered scapular movement therefore have changes in scapulohumeral rhythm
Pain in the top and lateral side of the shoulder which is made worse by lifting the arm (for example when lifting a full kettle) or with overhead activities
There can be night pain
Active movements are painful and may be restricted, whereas passive movements tend to be full but painful
May be a painful arc of movement between 70-120 degrees of abduction (presence reinforces the diagnosis of a rotator cuff disorder)
Weakness &/or pain on isometric resisted testing - joint does very little mvt
Management of RCSRP
○ Surgery vs Physiotherapy - some evidence suggests that they have similar outcomes
○ Physiotherapy includes:
Load modification - at first progression back to normal activities as soon as pain allows
Education - on pathology and on reducing aggravating activities
Pain relief - NSAIDs / Ice / joint mobs / SSTMs
Exercise:
Improve Strength and tissue capacity
Exercise in one direction at a time eg. ER
Restore full AROM & PROM
Isometrics (if irritable)> Isotonic
Start slow (this biases muscle, fast exs biases tendon)
Don’t exercise at EOR
Work into ER – this increases SAS & decreases pressure on RC tendons
Add other movements (e.g. LR with abd)
Progressive dynamic strengthening of RC
Maintain & improve neuromuscular control
Maintain muscle strength of all shoulder muscles
Define Lateral epicondylitis/epicondylalgia (tennis elbow)
Most common overuse syndrome in the elbow
Tendinopathy involving the extensor muscles of the forearm
Epicondylalgia because no symptoms of tendinopathy
Affects radial nerve as it passes through heads of supinator - neural symptoms
Prevalence of Tennis Elbow
- Affects 1-3% of the population
- Male=Female
- More common in 40s/50s
- ECRB tendon is the most commonly affected; ECRL tendon 2nd most affected; Other common tendons affected = ED, EDM, ECU, supinator
Causes of Tennis Elbow
Repetitive activity involving the extensor tendons of the forearm - musicians, computer users, manual workers, racquet sports (improper training, poor technique, improper equipment)
Risk factors of Tennis Elbow
Smoking
Obesity
Prognosis of Tennis Elbow
○ Most cases are self limiting (90% recover within a year)
○ Re-occurance rate = 8%
○ If do not recover or reoccurance occurs - increased risk of surgery required
Clinical Presentation of Tennis Elbow
○ Pain located around the lateral epicondyle of the elbow, usually radiating in line with the extensors
Insidious onset but often related to H/O overuse without specific trauma
Symptom onset 24-72h after repeated wrist extensor activity
○ Variable pain reported – intermittent / continuous, varying in severity
○ Typically aggravated by resisted wrist / finger extension, forearm supination; Middle finger causes secondary stress to ECRB - ECRB acts as a fixator on 3rd MC
○ Stretching the tendon can also reproduce symptoms, as can gripping - increases compression on common extensor tendon
Eases with rest
Differential diagnosis:
- Radiohumeral bursitis
- Osteochondritis of capitulum
- Posterior Interosseous Nerve (PIN) entrapment - In some cases the radial nerve may become involved as the radial nerve splits into the superficial radial nerve and the posterior interosseous nerve (PIN) at the radiocapitellar joint. Neurological deficit: weakness of posterior interosseous nerve innervated muscles (finger and thumb extensors and abductor pollicis longus)
- Radial tunnel syndrome - PIN may become trapped by pericapsular structures
- Diffuse aching pain over wrist extensor muscles, possibly radiating to the dorsal aspect of the hand, or sharp, shooting pain along the dorsal forearm region. Pain often worse at night
- Rarely, sensory or motor changes
- Pain may be increased by resisted supination, neurodynamic tests, and/or nerve palpation
- Cervical radiculopathy
- Radiation of pain from cervical spine, reproduced by palpation and/or active or passive movements of the cervical spine
- Focal motor, reflex, or sensory changes associated with the affected nerve
- Elbow and forearm overuse injuries
- Medial epicondylitis
Medical Management of Tennis Elbow
NSAIDs - i.e. ibuprofen, naproxen
Corticosteroid Injections
Shockwave Therapy
Surgery - severe cases
Physiotherapy Management of Tennis Elbow
Load Management - stop under/overuse
Exercise:
Stretching:
- Prayer stretch
- Wrist extensor stretch
- Thumb stretch
- Wrist flexion/extension
- Forearm pronation/supination
- Elbow flexion/extension
Wrist extension re-training:
Sensorimotor palm-slide exercise for retraining of wrist extension. With the forearm resting in pronation on a table, the wrist should be slowly extended by sliding the fingertips along the table and lifting the knuckles. Emphasis is placed on avoiding metacarpophalangeal extension and finger flexion. Return to the starting position and repeat 10 times
Strengthening:
Wrist extension exercise can be performed over the edge of a table with elastic tubing or free
weights.
Isometric holds (30-60 seconds in duration)
are advocated for reactive or irritable tendinopathy,
while concentric and eccentric actions should be
performed slowly (4 seconds for each direction),
completing 2 to 3 sets of 10 repetitions for patients
with less irritable or degenerative tendinopathy, only moving in non-painful ROM.
Emphasis is placed on maintaining neutral radialulnar deviation of the wrist (by aligning the middle
metacarpal bone with the long axis of the forearm).
Progression may be achieved by increasing load
or performing the exercises with greater elbow
extension
Wrist radial deviation exercises
Forearm pronation supination exercises
Exercises should also address motor
control impairments, such as dissociation of wrist from finger extension and retraining of wrist alignment during gripping
Brace / Taping - reduce symptoms allowing them to calm down
Education - what the problem is, reduction of aggravating activities
Define Medial Epicondylitis/epicondylalgia (golfers elbow)
Overuse tendinopathy, similar to tennis elbow but affecting the common origin of the flexors and pronators
Affects ulnar nerve passing through heads of FCU - neural symptoms
Prevalence of Golfer’s Elbow
- Prevalence 0.3-1.1%, Female > Male
- Significantly less common than LE (approx. 10% incidence in comparison)
- Age 40-60
- Associated with golf, manual workers
- Involves Pronator Teres and FCR
Prognosis of Golfer’s Elbow
60% recover w/ conservative treatment
Clinical Presentation of Golfer’s Elbow
○ Pain on the medial aspect of the elbow – tender on palpation
○ Aggravated by resisted / repetitive wrist flexion or pronation, valgus (ABD) stress, stretching tendons
○ Aggravated by throwing / gripping
○ Reduced grip strength
○ Can involve ulnar nerve (20%) - Dermatome of ulnar nerve = little finger, ring finger (excluding fingertip)
Medical management of Golfer’s Elbow
NSAIDs
Shockwave Therapy Corticosteroid injections
Surgery
Physiotherapy management of Golfer’s Elbow
Load management - gradual increase
Exercise - Strengthening exercises of wrist flexors and forearm pronators
Education
Taping / bracing - offload to reduce symptoms
Define De Quervain’s Tenosynovitis
Reactive thickening (inflammation) of the tendon sheath around EPB and APL
Prevalence of De Quervain’s Tenosynovitis
Tenosynovitis can be caused by unaccustomed movement, overuse or repetitive minor trauma of the thumb; May occur spontaneously (idiopathic)
The resulting synovial inflammation causes secondary thickening of the sheath and stenosis of the compartment, which further compromises the tendon.
The first dorsal compartment (APL & EPB) and the second dorsal compartment (ECRB) are most commonly affected.
The flexor tendons are affected far less frequently.
Overuse may involve eccentric lowering of the wrist into ulnar deviation with load, e.g.
- Lifting heavy dishes
- Painting
- Golf
- Hedge trimming
- Pruning
- Wringing activity
More common in women - 1.3% vs 0.5% (male)
More commonly reported in new mothers - the way they lift their babies involves eccentric ulnar deviation
Age most commonly 40s-50s
Pathology of De Quervain’s Tenosynovitis
The extensor retinaculum contains 6 compartments which transmit tendons lined with synovium
Inflammation of synovial sheaths of EPB & APL
Swelling of the sheaths and eventual thickening as swelling becomes organised
Adhesions may develop between tendon and sheath restricting normal tendon movement
Constriction of enclosed tendons = ‘stenosing tenosynovitis’
Clinical presentation of De Quervain’s Tenosynovitis
Pain on the radial side of the wrist that can be referred to the thumb
History of unaccustomed activity
Visible swelling over distal end of radius
Tendon sheath feels thick and hard
Tenderness most acute at tip of radial styloid
Weakness of grip
Aggravated by resisted thumb extension / abduction, or by stretching the affected tendons (Finkelstein Test)
Finkelstein’s Test
- Patient makes a closed fist with thumb tucked inside
- Passive ulnar deviation is performed maintaining the wrist in a neutral position
- Positive: reproduction of pain
- Negative: uncomfortable but not painful
Medical management of De Quervain’s Tenosynovitis
NSAIDs
Corticosteroid Injection Surgery
Physiotherapy management of De Quervain’s tenosynovitis
Splinting - calm symptoms however symptoms may reappear after splint removal; To rest the fingers and thumb for a period of 3 to 4 weeks.
Load Management - increase ability of tendon to w/stand load; gentle return to activity enouraged
Education - what the issue is, reduce activities aggravating symptoms
Exercises - strengthening of APB and EPL
Define Strains
Muscle or tendon injury – involves over contracting or lengthening a muscle causing tearing of collagen
Grade 1 of a strain/sprain
Mild, overstretched, micro-tears
Localised pain and tenderness
Minimal bruising/swelling/loss of function
No loss of strength and ROM
Grade 2 of a strain/sprain
Moderate, partial-tears
Immediate onset of all inflammatory signs
Poorly localised pain
Moderate swelling/bruising/loss of function
Painful and reduced ROM
Reduced strength and painful resisted movement
Grade 3 of a strain/sprain
Severe, complete tear
Inability to contract, separation may be evident
May hear audible ‘pop’ or ‘crack’
Immediate swelling, pain and bruising
Over time symptoms may be lower than grade II
Prevalence of strains
- More common in 2+ joint muscles as greater risk of overstretching
- Eccentric contractions (deceleration phase)
- Muscles with higher percentage of type II fibres
Medical management of strains
○ Surgery - for grade III; physiotherapy required afterwards
Physiotherapy management of strains
Depends on severity of strain – healing times
POLICE - protection, optimal loading, ice, compression, elevation; PRICE - swap optimal loading for rest.
Mobilisation – as soon as possible because increases chance of recovery
Strength / loading - once full ROM is recovered
Proprioception - after strengthening
Endurance training - depending on patients goals/lifestyles
Define Sprains
Stretch and/or tear of a ligament
Usually caused by the joint being forced suddenly outside of its usual ROM, and the inelastic fibres are stretched to far
Prognosis of sprains
most recover with conservative management
Although most severe require surgery to reconstruct ligament
Prevalence of sprains
Commonly occurs in ankles
Physiotherapy management of sprains
similar to strains
○ Dependent on severity – healing times
○ POLICE - protection, optimal loading, ice, compression, elevation; PRICE - swap optimal loading for rest.
○ Early mobilisation - increase chance of recovery
○ Early weightbearing - if appropriate
○ Exercises - encourage mobility in a safe way
○ Education - about injury and healing
○ Return to sport (if applicable)
○ Surgery - severe cases; physio required post-surgery
Define Carpal Tunnel Syndrome
Median nerve is compressed where it passes through the carpal tunnel
Prevalence of Carpal Tunnel Syndrome
Most common peripheral nerve entrapment syndrome
1 in 10 people develop carpal tunnel at some point
Female>Male - more significant difference with increasing age
Younger presentations usually have coexisting pathologies
Risk factors:
- Diabetes (Type I and II)
- Menopause
- Hypothyroidism
- Obesity
- RA
- Pregnancy
- Family history
- Female>Male 8:1,
- Age 40-50, chances increase after this age
Causes of Carpal Tunnel Syndrome
Oedema, tendon inflammation, hormonal changes, cysts in the carpal tunnel, repetitive manual activity can contribute to nerve compression in this area
Prognosis of Carpal Tunnel Syndrome
Depends on severity of symptoms:
Mild to moderate – respond well to conservative (mild = 6 weeks ->referred to another physio for opinion)
Severe – more likely to require surgery
Clinical presentation of Carpal Tunnel Syndrome
Begins with intermittent nocturnal Pain, paraesthesia, anaesthesia in thumb & lateral 2½ fingers, that increases in frequency, then develops into waking hours
More severe cases – weakness of median nerve innervated muscles atrophy (thenar eminence wasting)
Whole hand may become affected and pain/aching may extend up into the forearm
Can progress to difficulty with fine motor tasks - as thenar eminence muscles weakened -> loss of thumb flexion, ABD, ADD, opposition
Difficulty fine motor tasks, gripping things, often drop objects.
Prolonged and intense symptoms.
Uni or bilateral - Dominant hand tends to be worse affected.
May be unable to differentiate between hot and cold.
Aggs - physical activity
Eases - hanging arm over side of bed & shaking hand
Assessment:
Observe and palpate for tenderness, swelling, warmth, discolouration.
Sensation testing of fingers, thumb, palm using gentle touch or pin-prick is suggestive of the condition if numbness, i.e. Positive.
Hot and cold sensation testing may reveal deficiencies if positive too.
Thenar eminence muscle strength tests may reveal weakness and atrophy here may be observed. Resist thumb actions of flexion, abduction and opposition.
Tinel’s sign – tap sharply over the median nerve on the anterior aspect of the wrist (sharp tingling in fingers is positive for the condition).
Phalen’s test active flexion of the wrist(s) for up to 1 minute (sharp tingling in thumb and fingers is positive for the condition).
Differentiate with cervical spine pathology
Management of Carpal Tunnel Syndrome
Education – lifestyle modification
Load management
Splinting – night time; calm symptoms during sleep
Exercise
Corticosteroid Injection - if conservative measures are not working
Surgery - if conservative measures are not working
Define Adhesive Capsulitis (frozen shoulder)
Formation of excessive scar tissue or adhesions across the glenohumeral joint leading to stiffness, pain and dysfunction
Affects glenohumeral ligaments and joint capsule
Prevalence of frozen shoulder
Common, debilitating condition
Reported prevalence of 2-5%
Most common in 40-60 year age group
Affects women > men
Characterised by pain & stiffness in the shoulder which passes through 3 stages
20% incidence in patients with diabetes
Bilateral involvement in up to 40-50% of cases
Self-limiting condition - 3 consecutive phases; spontaneous resolution
Prognosis - Mean duration from onset to recovery: 30 months
Usually leads to full functional recovery within 1-4 years but studies show 20-50% of patients had permanent restriction to movement compared to the uninvolved side, however, only 11% reported residual functional limitations
Types of Frozen Shoulder
Primary (idiopathic) - occurs spontaneously
Secondary – often after trauma, e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis
Risk factors of Frozen Shoulder
Female (70%) > Male (Males respond less well to treatment)
Previous AC in other arm
Age >40
Trauma - e.g. #, shoulder surgery, fall that does not cause a specific shoulder injury but leads to adhesive capsulitis
HLA-B27 +ve - blood test indicating if high risk of developing autoimmune diseases
Ankylosing spondylitis
Reactive arthritis
Cerebrovascular Disease
Coronary Artery Disease
Diabetes - 20% incidence; these patients have worst outcomes - more likely to have longer lasting symptoms, bilateral symptoms, recurrence
Hyperthyroidism
Previous/current Dupuytren’s disease
Stage 1/3 of Frozen Shoulder Pathology
Painful (Freezing) Phase (2-9 months)
Primary complaint of shoulder pain, especially at night
Arthroscopically – evidence of synovitis (inflammation of synovium) without adhesions
Histologically inflammatory cell infiltration of the synovium
Stage 2/3 of Frozen Shoulder Pathology
Stiff (Frozen) Phase (4-12 months)
The pain becomes less severe but is present at the EOR. Stiffness remains and there
is reduction in the range of shoulder movements. Function can be substantially limited.
Arthroscopically synovitis is resolved (inflammation settled), significant adhesions – axillary fold obliterated
Histologically - Dense collagenous tissue within capsule
Stage 3 of Frozen Shoulder Pathology
Recovery (Thawing) Phase (12-42 months)
Gradual improvement in range of movement with less stiffness
Clinical presentation of Frozen Shoulder
Usually present first with gradual onset of shoulder pain & is felt at deltoid region
Followed by painful and gradual loss of AROM & PROM in capsular pattern (LR > Abd > MR)
AROM/PROM affected as inert tissue affected by adhesions formed
Decreased ER on AROM & PROM is usually sufficiently diagnostic; seen as difficulty putting on jacket
Passive ROM with firm, painful end feel
Inability to sleep on affected side
X-rays = normal - Imaging not necessary for diagnosis but can rule out other conditions, i.e. OA, pancoast tumour - lung cancer at apex of the lungs; <1% patients of stiff shoulder have this; 25% patients w/ this tumour have delayed diagnosis because of misdiagnosed shoulder problems
Medical management of Frozen Shoulder
- NSAIDs
- Corticosteroid Injections - reduce pain and inflammation
- Hydrodilatation - injection of large amount of fluid into shoulder joint capsule to stretch it out and tear adhesions apart (Less invasive than surgery)
- Surgery - 2 types: Capsular Release (safer than MUA), MUA (Manipulation under anaesthesia)
Physiotherapy management of Frozen Shoulder
Early mobilisation
Early pain management is key to allow this
Manual therapy and exercises included
Education
the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover
Determine:-
- main problems
- phase 1,2 or 3
- SIN factors - pain will be guiding factor to alter rehab: stretches to discomfort but not to pain
Painful phase:
Key aim: reduce pain
<3/12 consider CSI
>3/12 avoid CSI - seems to increase length of time of resolution
NSAIDs?
ADVICE - the patient must understand the process of frozen shoulder and that it may take 1-4 years to recover
Maximise ROM
Freezing phase
Key aim: maximise ROM and function
Mobs
Self-management programme - RC interval (supero-anterior capsule) stretched in neutral ER
Advice
Resolution phase
Key aim: maximise ROM restore function
Active exercise programme /self-management programme
Mobilisation/stretching
Prevalence of Clavicle #
Mostly result from a fall, normally on to shoulder - fall on side of shoulder or FOOSH
Neuro / vascular structures nearby can be affected, i.e. brachial plexus, subclavian vessels
Mid-shaft (most common) > Lateral (2nd most common) > Medial (4.5% of clavicle #)
Medical management of clavicle #
Surgical - more severe injuries - displaced #
Similar physio treatment post-op
Physiotherapy management of clavicle #
Conservative - less severe injuries - non-displaced #
Sling use - usually 3 weeks
Physiotherapy - involves early mobilisation of shoulder and shoulder girdle, progression into loading, as appropriate
Prevalence of proximal humerus #
Normally occurs as a result of a fall
Third most common fractures in the elderly, more common in women (2:1)
Classified depending on how many fragments are displaced:
1-part # = no displacements
2-part # = 1 displacement
3-part # = 2 displacements
4-part # = 3 displacements
Management of proximal humerus #
Collar and cuff (2-3/52) - type of sling with a pink foam material
Followed by progressive active management
The more elderly the patient the slower they progress and are more likely to be left with reduced ROM and function post-treatment; could result in frozen shoulder
Surgery - most severe cases require surgical fixation
Prevalence of distal radius #
Commonly occurs due to FOOSH
Types of distal radius #
Colles’ Fracture – most common – extra-articular (# occurs out of joint capsule), dorsally displaced distal radius fracture; associated with dinner fork defomity
Smith’s Fracture – extra-articular, anterior displacement of distal radius
Barton’s Fracture – intra-articular fracture with associated dislocation of the RCJ
Medical management of distal radius #
Splint
Casts
K-Wires - for fixation (lasts 4-6 weeks) - inserted into bone and hook remains outside of body, allowing for wires to be removed later
Surgery - MUA
Physiotherapy management of distal radius #
Physiotherapy following period of immobilisation - involves manipulation to re-align #
Mainly to increase mobility, strength and function at wrist
Prevalence of Scaphoid #
Most commonly fractured carpal bone (70% of carpal bone #)
Often from a FOOSH
Waist (80% scaphoid #) > Prox Pole > Distal pole (least at risk)
Proximal pole has poor blood supply -risk of AVN
Risk of non-union (5%)
Pain over anatomical snuffbox
Approx 25% initial scaphoid # not seen in X-ray - if in doubt patient wrist will be immobilised and X-ray repeated in 10-14 days later when its more visible
Management of scaphoid #
Cast - period of immobilisation
Surgery - more severe cases require surgical fixation
Physiotherapy after immobilisation period - mainly to improve mobility, strength and function
Prevalence of OA
○ Most common form of arthritis, can develop in any synovial joint.
○ Most common in knees, hips and small joints of hand.
Medical management of OA
Corticosteroid Injection
Surgery - most severe cases; joint replacements (common), debridement
Physiotherapy management of OA
§ Exercises for mobility and strength
Hydrotherapy - different form of exercises in hydrotherapy pool; warmer (34oC) than standard pool, providing therapeutic affect; buoyancy of pool also provides a therapeutic affect
Manual therapy
Education
Define Rheumatoid Arthritis (RA)
Systemic autoimmune disease (body’s immune system attacks the joint) characterised by inflammatory arthritis with extra-articular involvement
Pathology of RA
Synovium is infiltrated by immune cells.
Fibroblasts and inflammatory cells lead to osteoclast generation resulting in bone erosion and loss of joint integrity.
Systemic inflammation and autoimmunity in RA begin long before the onset of joint inflammation
Prevalence of RA
○ Most prevalent in North America and Northern Europe
○ Female > Male - 2-3:1
○ Prevalence increases with age
○ Paediatric population – RA = Juvenile Idiopathic Arthritis; Idiopathic = occurs spontaneously or w/out a known cause
○ Polyarthritis of small joints of hands – PIP, MCP, RCJ
○ Other commonly affected joints – elbows, shoulders, hips, knees, ankles, MTP
Risk factors of RA
Genetic Factors (non-modifiable)
Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D
Clinical Presentation of RA
○ Insidious (gradual) onset over a period of months
○ Joint stiffness in the morning
○ Fatigue
○ Deformity (formed overtime due to bone erosion and loss of joint integrity)
○ Pain
○ Weakness and restricted mobility in affected joints
○ If Cx is involved it can lead to cervical instability between C1 and C2 - affecting dens and surrounding ligts = reducing stability
Medical management of RA
GOAL = symptom management Pharmacological management (key treatment) – Disease Modifying Anti-Rheumatic Drugs (DMARDs) Nutrition - help with symptom management
Physiotherapy management of RA
Appropriate exercise programme to maintain mobility, strength and function for as long as possible; also to manage flare-ups
Advice and education
Define shoulder dislocation
Dislocation can occur anteriorly or posteriorly (<5%) - humeral head dis-articulates either anteriorly/posteriorly
What are the static and dynamic shoulder stabilisers
ANATOMIC:
Labrum: triangular fibrocartilaginous rim attached around margins of fossa & improves joint congruency as well as providing a surface of attachment for glenohumeral ligaments
Continuous with biceps long head tendon – important for SLAP lesions
Negative intra-articular pressure
STATIC: Capsuligamentous structures
Ligaments:
- Glenohumeral ligaments:(thickenings of anterior capsule; superior, middle & inferior)
- Inferior g/h ligament most important in preventing anterior & inferior translation
- Middle g/h ligament resists ER & abd
Rotator cuff tendons blend with & re-inforce capsule superiorly by supraspinatus, anteriorly by subscapularis, posteriorly by teres minor & infraspinatus
Coracohumeral lig + superior capsule + inactive supraspinatus provide static stabilisation in dependent arm
Capsule:
- Capsule is thin & is strengthened by the ligaments (glenohumeral & coracohumeral) & the muscles. Inferior part of capsule is thinnest, dislocation most common in this direction.
- Lax capsule allows large ROM
- Tight inferiorly on abd.
- Tight ant on ER
- Tight post on IR
DYNAMIC:
Rotator cuff:
Reinforce capsule – static stability
Provide dynamic stability
Produce compressive force
Maintain optimal relationship of HH with glenoid through ROM - resist & control HH translation
Maintain sub-acromial space & Prevent impingement
Any imbalance in RC can lead to disturbed S-H rhythm & dysfunction eg. impingement
Supraspinatus & deltoid important compressors at 90° abd.
Subscap. important in decreasing displacement aided by infraspinatus
Rotator crescent = area of relative avascularity approx 1cm from insertion of supraspinatus & infraspinatus tendons
Stability heavily dependent on muscles to maintain integrity
Structures limiting inferior translation:
- Negative intra-articular pressure
- Superior GH ligament
Structures limiting anterior translation:
- Anterior capsule and ligs - GHL
- Subscapularis & long head of biceps tendon
- Inferior GH ligament (in abduction)
Structures limiting posterior translation:
- Posterior capsule
- Inferior GH ligament
- Teres minor & infraspinatus tendons
Pathology of Anterior Shoulder Dislocation
Movement on its own = anterior glide of humeral head on glenoid fossa
Inferior GH ligt = primary ligamentous restraint to ant displacement
Prevalence of Anterior Shoulder Dislocation
Often caused by the arm being positioned in abduction and external rotation (apprehension position); apprehension position used for shoulder instability tests
In this position there is often a AP force resulting in humeral head displacing antero-inferiorly
Can result in many types of lesions
Concurrent rotator cuff injuries can also occur
Vascular / neural structures at risk - particularly structures w/in axilla and brachial plexus
What lesions can an Anterior Shoulder Dislocation result in
Hills-Sachs lesion - small # or cortical depression (depression in bone) on posterolateral aspect of humeral head; caused by impaction of humeral head against rim of the glenoid as dislocation occurs
Bankart lesion - damage to attachment point of the labrum to the glenoid margin; normally occurs anteriorly to anterior dislocation; Bony Bankart lesion = if associated w/ # of glenoid sometimes
Superior Labrum Anterior and Posterior (SLAP) lesion - Tears of the superior labrum near to the origin of the long head of biceps; common in throwing athletes
Humeral Avulsion Glenohumeral Ligament (HAGL) lesion - Inferior Glenohumeral Ligament is ripped off the humerus with dislocation of the shoulder
Anterior Labral Periosteal Sleeve Avulsion (ALPSA) lesion - the anterior labro-ligamentous complex rolls up in a sleeve -like fashion and becomes displaced medially and inferiorly, “the medialised Bankart lesion”
Prevalence of Posterior Shoulder Dislocation
Usually caused by a blow to the front of the shoulder often with the arm flexed at the shoulder in adduction and internal rotation
Can also occur during seizures or electrocutions
Can be easily overlooked on an AP x-ray
Concurrent injuries to rotator cuff (mainly subscap) and posterior labrum, HOH # (can progress to AVN or OA)
On examination person may hold the shoulder in adduction and internal rotation. There may be an abnormal shoulder contour
Prognosis of shoulder dislocations
19.6% recurrence rate, mostly in first two years
Higher recurrence rate in males
Higher recurrence in younger patients (49.2% if aged 10-19)
Those with recurrence are more likely to have a shoulder stabilisation surgery
Define Shoulder Instability
Unable to control or stabilise the joint during motion or in a static position either because static restraints have been injured or because muscle controlling the joint are weak or the force couples are unbalanced
Characterised by disruption of the dynamic and static stabilisers of the GHJ leading to subluxation (partial loss of contact between joint surfaces) or dislocation (the complete loss of contact between joint surfaces) or apprehension
Causes of Shoulder Instability
Traumatic (96%):
Shoulder is dislocated by an external force
As the shoulder does not heal in the correct anatomical position, or structures do not heal properly, the person is more susceptible to recurrent dislocations and further damage
Atraumatic:
From chronic recurrent use, causing change in mobility of the shoulder
Congenital - secondary to hypermobility syndrome or ehlers-danlos syndrome - affects connective tissue structure causing laxity of static stabilisers in shoulder
Common in adolescent females with hypermobile joint
Risk factors of Shoulder Instability
Previous dislocation = damage to static stabilisers - more likely to get recurrent dislocations because they have shoulder instability
Types of Shoulder Instability
Anterior
Posterior
Inferior
Multidirectional - often caused by congenital conditions because they cause a general laxity in static stabilisers
Classifications of shoulder instability
PRIMARY : Dislocation
T : traumatic
U : unidirectional instability - MOI: anterior most common (98%):ER+ABD; Posterior (2%)
B : Bankhart lesion - Capsular tear +/- detachment of labrum (labral tears common in throwing athletes); anteroinferior tear to labrum
S : Surgery
Apprehension in certain positions, decreased ROM into Abd + LR
SECONDARY : Poor neuromuscular control
A: atraumatic
M: multi-directional instabilty
B: bilateral
R: rehabilitation
I: inferior capsular shift
No history of injury
Excessive capsular / ligament laxity OR decreased neuromuscular control / muscle imbalance – may be related to posture / type of use
May predispose to impingement in young age group
Inferior instabilities are usually part of multidirectional instability
CONGENITAL
osseous/labral defect
Soft tissue abnormality
Clinical Presentation of Shoulder Instability
General
Clicking / Pain
Positive apprehension test / relocation test (anterior) / load & shift test
Increased accessory motion at GHJ in the direction of instability; increased ROM compared to other limb
Positive sulcus sign
Age < 35
H/O shoulder feeling that it moves partly or completely ‘out of joint’ and may be concerned their shoulder may dislocate during certain activities or sports
If the instability is longstanding, there may be hand or arm weakness, tingling or numbness from proximal nerve traction
Primary (traumatic)
Pain around ant.lat. shoulder
Limited AROM
RHS rhythm
Positive apprehension test
Neural / vascular changes
Wasting of deltoid/rotator cuff
Secondary (atraumatic)
Full or excessive ROM
Pain at EOR on movement
Clunking, sensation of ‘coming out’ of joint
Dead arm on overhead activities – particularly with anterior instabilities
Loose / empty end feel on passive testing
Positive stress tests - sulcus test, anterior aprehension test, load & shift tests
Medical management of Shoulder Instability
Surgery – depending on structural impairments, i.e. labral tears
Physio takes a post-op role after a period of immobilisation (4 weeks)
Physiotherapy management of shoulder instability
primarily focused on training dynamic stabilisers
Neuromuscular retraining +++
Stretching / mobilisation tight capsule / rotator cuff
Other structures may require stretching, i.e. pectoralis majors shortened = pulling shoulder anteriorly
Postural re-ed
Strength Training - of deltoid - plays stabilising role in GHJ
Proprioception Training
Define Dupuytren Disease
Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis)
Pathology of Dupuytren’s Disease
- Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis) resulting in;
- Flexion contracture of the MCP and PIP joints leading to loss of function
- Occurs slowly, typically progresses over the course of several years; normally affects 4th and 5th fingers but can affect others
- Commonly begins with thickening of the skin, then bands (palpable at first; only visible over time) of fibrotic tissue form in the palmar area caused by fibroblast proliferation causing collagen deposits, leading to contracture of palmar fascia (aponeurosis)
- Eventually leading to the affected fingers being pulled into flexion.
- Typically occurs bilaterally
Prevalence of Dupuytren Disease
An inherited autosomal dominant trait
Most common in people of Northern European descent
Males > Females - difference becomes less with increasing age
Average age of onset 60, incidence increases with increasing age
Onset at an early age usually means aggressive disease
Environmental Factors – alcohol intake, smoking, manual labour, low body weight / BMI, use of anticonvulsant drugs
Associated with diabetes, epilepsy, HIV, adhesive capsulitis, cancer
Clinical features of Dupuytren’s Disease
Nodular thickening, palm
Gradually extends distally
Involves ring &/or little finger
Pain, seldom marked
Bilateral, 1 more than other
Palm is puckered, nodular & thick
Flexion deformities at MCP & PIP joints
Dorsal knuckle pads may be thickened (Garrod’s pads)
Medical management of Dupuytren Disease
Surgical Intervention is the mainstay of treatment; different levels of surgery depending on severity:
- Simple fasciotomy – early stage DD, contracted cord is cut through small incisions but not surgically removed – least invasive
- Fasciectomy – partial or total removal of the diseased palmar fascia including the contracted cord / nodule
- Dermofasciectomy – removes all diseased tissue, also removes overlying skin and fat, then required a full thickness skin graft to cover the surgical site – severe, recurrent Dupuytrens
- Amputation of the digits may be considered as a last resort
Physiotherapy management of Dupuytren Disease
Aimed at restoring mobility at finger joints
Pre-operative:
- Splinting
- Massage
- Passive stretching
- Active exercises
Main role is post-operative:
- Splinting - can be custom-made by hand therapists
- Passive stretching
- Active exercises
- Strengthening
- Functional activities
- Education and advice
- Oedema and scar management - really important because if scar begins to contract leads to recurrence
Prognosis of Dupuytren disease
Following surgery, prognosis is good initially
Recurrence is frequent
Early onset carries poorer prognosis
Proximal IP joint contractures soon become irreversible
Define Acromioclavicular joint injuries
Acromioclavicular joint injuries can involve stretching or tearing of the acromioclavicular or coracoclavicular ligaments and subluxation or dislocation of the acromioclavicular joint
Aetiology of Acromioclavicular injuries
Most commonly occur in men aged 20-50 years
MOI: a fall onto the point of the shoulder during sporting activity or FOOSH
Grade I: Intact joint with minor tear of the acromioclavicular ligaments.
Grade II: Up to 50% vertical subluxation of the clavicle with rupture of the acromioclavicular ligament and stretching of the coracoclavicular ligaments.
Grade III: more than 50% vertical subluxation of the clavicle with complete rupture of both acromioclavicular and coracoclavicular ligaments
Clinical features of an acromioclavicular subluxation/dislocation
tenderness localised to the AC joint, limited range of movement due to pain, high arc pain or a positive cross arm test
Step deformity, TOP - increased clavicle angle to acromion
Decreased HF / elevation. above 90º
Management of acromioclavicular subluxations/dislocations
Conservative:
POLICE +
Mobilisation - if stiffer
Active exs
Surgical:
A/C joint stabilisation using coracohumeral ligament
Surgical management of A/C joint only in cases where there is continuing pain or disability or failure of conservative treatment 3 months post injury
