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Shoulder Injuries
Shoulder Injuries
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Functional Anatomy
The glenohumeral joint is an inherently unstable shallow ball and socket joint.
Effective Sh function and stability require both:
Weakness and/or poor motor control of stabilizers ( +/- weak rotator cuff)
Rhomboids
Levator scapula
Pectoralis minor
They work in force couples to control 3D mvt of the scapula
Ant/ post tilt and 1 = Upper traps/Pecs minor with Seratus ant/Lower traps
Clinical Perspective
Diagnoses of Sh pain Requires: Thorough history, Thorough examination and Appropriate investigation
organization
Piactical Appioach to Sh pain
Numerous structures can cause Sh painfirst narrow the prob down to one of the following
catagories:
1. Rotator cuff
2. Instability
3. Labral injury
4. Stiffness
5. AC joint pathology
6. Referred pain
1 .Rotatoi cuff muscles anu tenuons
Injuries to the muscles/tendons may be acute, chronic or acute on chronic.
- Acute = muscle strain, partial or complete tendon tear
- Overuse= Tendinopathy
- Acute on chronic = eg. complete tear on previously degenerative tendon
Rotator cuff tendon injuries present with sh pain and difficulty with overhead activities
2. Sh instability
Pain arises from ant/post or superior Sh capsule and labrum or pericapsular mm.
May be obvious in pt with recurrent dislocation/subluxation
Instability may result from :
- Hyper mobility (Changes to passive structures like ligt, capsule, labrum)
- Dynamic instability ( Poor motor control)
S.Labial injuiy
From acute or overuse injury.
May lead to instability.
4.Sh stiffness
Hypomobility may be due to :
- Trauma (surgery, injury to cervical nerve roots, brachial plexus injury)
- Spontaneous in middle age ( idiopathic capsulitis / frozen Sh)
S.AC }oint Pathology
Localized pain
6.Refeiieu pain
From:
- Cervical spine
- Upper thoracic spine
- Associated soft tissue
Shoulder dysfunction can lead to traps fatigue or radiate to:
- Neck
- Behind scapula
- Upper arm
- Fore arm
- Wrist + hand
Bistoiy
Most Sh pain is diffuse (AC and bicipital pain is well localized)
1. Onset may be:
- Accute (Dislocation, subluxation, rotator cuff tear)
Identify Sh position at time of injury - wrenching = ant subluxation or dislocation
Fall onto Sh = AC joint injury
- Insidious (Tendinopathy)
In Chronic pain the painful position/activity of the Sh should be noted
2. Note the severity of pain, easing/aggravating factors and the effect of P on ADL/sport
3. Sensory symptoms ( pins and needs, dead arm in a pitcher suggests labral injury-)
4. Assess UL strength
5. May report catching/locking or inability to develop N speed.
6. Problems elsewhere in the kinetic chain eg. Knee or ankle or lower back pain
7. Exact physio for previous local or distant problems
8. Predisposing factors (over training ect)
Examination
Resisteu mvt
1. External Rotation (Pic)
2. Gerbers test (Sub scap lift-off)
3. Deltoid (Resisted abd @ 90)
4. Empty can (Supraspinatus)
- (90 abd, 30 horizontal flex, full internal 1)
- ! strength with Scap retraction = rotator cuff is NOT injured but is weak due to scapular dyskinesis
5. Long head of biceps tendon (upper cut)
Special Tests
1. AC Joint
a) Modified OBreins test (+ if pain in this position - 90 flex,10 hor flex, max int 1)
b) Active Horizontal flexion (Closing of AC joint)
2. Supraspinatus Impingement
a) Neer Test (+ if elicit known pain while moving greater tuberosity under acromion)
b) Hawkins and Kennedy (forcefully int 1 Sh from 90 flexion - remember to stabilise Scap)
c) Empty can (90 abduction, 30 hor flex, full int1)
d) Scapular assistance test (# pain = +)
e) Scapular Retraction test ( + If Impingement signs are #)
3. Long Head Of Biceps Tendinopathy
a) Speeds Test b) Uppercut c) Yergesons test (Resisted supination)
4. Instability
a) Load shift test drawer test
b) Apprehension Relocation test (Anterior) (+ if pain is relieved with relocation)
c) Sulcus test (Inferior)
d) Posterior instability test (supine, 90 flex, give compression through Sh joint AP)
5. SLAP Lesion
a) Dynamic Labral shear (NB maintain tension with external rotation)
b) OBriens Test ( Pain Supinated<Pronated)
c) Crank test (160 abd)
d) Anterior slide
6. Scapular mvt
a) Lateral slide test (Measured with arm by side,hand on hip and 90 abd. Compare L = R)
Sh Investigations
X-iay
Can identify:
- Joint space
- Dislocation
- Calcific Tendinopathy
- Arthritis
- Sclerosis
- Humeral head migration
- Fractures
Aithiogiaphy
Stain is used in combo with CT or MRI and
allows detail examination
Scapular Dyskinesis
Cervical Radiculopathy
Biceps Tendinopathy
GH instability
GH internal 1 deficit
Sh impingement may be External (primary or secondary) or Internal
Piimaiy exteinal Impingement (Bony cause)
Abnormalities in superior struct lead to encroachment into the Subacromial space.
Undersurface may be beaked, curved or hooked.
Cause can be a congenital abnormality or osteophyte formation.
Abnormalities that tend to occur in the older pt include osteophyte formation on the inf surface of
the ac joint and thickening of the coracoacromial arch
In any sports person presenting with
impingement, NB to consider superior labral
injury or instability. These may lead to
impingement and if untreated the symptoms
will persist.
Seconuaiy exteinal impingement - biomechanic of nature
Encroachment in the younger athlete may be resultant from Excessive angulation (Excessive internal
1 and ant tilt) of the acromion due to inadequate scapular stabilization
Muscles may be deficient due to:
1. Altered activation in force couples
2. Altered strength balance
This results in failure to adequately control the Scapulohumeral rhythm, thus abnormal scapular mvt.
The tilt and rotation = narrowing of the Subacromial space = symptoms.
This is the exacerbated by pec minor tightness that pulls the scapula into protraction.
If an imbalance between the HOH elevators (Deltoid) & the HOH stabilizers (Rotator cuff) exists:
HOH will move superiorly with deltoid contraction forcing it against the rotator cuff tendons and
narrowing the
sub AC space.
Inteinal impingement - Look for laxity and labral injuries too
Occurs mainly in overhead sports during the late cocking stage. (ext, abd, ext rot) when the undersurface
of the rotator cuff occurs against the posterior surface of the glenoid.
This normally a physiological occurrence, may become pathologic with repetitive trauma, overuse and
injury to the labrum.
Rotator cuff injuries
Rotatoi cuff Tenuinopathy
The tendon becomes: swollen, hyper cellular, with collagen matrix being disorganized
- leaving tendon weaker with an increase in vasculature and nerve density.
Volume of work is a major determinant in the onset of a Tendinopathy.
Sometimes calcifications can appear
- most often seen in the Supraspinatus tendon, but may occur in any
tendon.
- may be asymptomatic, however if symptomatic = severe pain at
rest, with mvt and at night
Clinical featuies
- Pt complains of pain with overhead activities
- Activities in < 90 abduction are usually pain free
- May have a history of instability
- Night pain is common
- Tenderness at or just proximal to the insertion of
Supraspinatus on the greater trochanter
- Painful Abduction arc (70-120 Abduction)
Int 1 is commonly # and Rotator cuff strength should be
assessed with the scapula stabilised
Sxs with impingement tests and with end range flexion
MRI = investigation of choice
Diagnostic US can:
- Rule out a full thickness tear & define a partial thickness tear
- Indentify a thickened Subacromial bursa and rule in/out impingement of the bursa under the lateral
acromion with abduction
Tieatment of iotatoi cuff Tenuinopathy
Treatment consists of 2 parts:
1. Treat the Tendinopathy itself (PRICEM)
- No level 2 evidence to support NSAIDS, US, IFST, Laser, Magnetic field therapy or Massage.
- Level 2 evidence for Nitric Oxide donor therapy (patches applied locally @ 1.25mg/day)
Successful outcomes within 3-6 months
- Subacromial corticosteroid injection to allow adequate rehabilitation
2. Correction of associated abnormalities (eg. Instability, muscle weakness, training errors etc)
- Decrease rotator cuff strength is also predisposition to the development of a Tendinopathy.
- Rx involves strengthening of the ext rotators (if there is an imbalance of int vs ext rotators)
- Posterior capsule tightness is associated with increased int rotation and rotator cuff weakness.
- Thus stretching of the posterior capsule is NB.
- Symptomatic pts fire trapezius, and asymptomatic fire lateral deltoid.
- No level 2 support for a specific rehabilitation strategy
3. Abnormalities along the kinetic chain must be identified and corrected
Calcific Tendinopathy can be difficult
Mature calcific lesions may be disrupted by Shock Wave Therapy
Can use Nirschl Phase Rating Scale for tendinopathies:
1. Mild stiffness or soreness after activity with resolution of symptoms within 24hours
2. Mild stiffness or soreness prior to activity that is relieved by warm-up; Sxs are not present
during activity but return afterwards and resolve within 48hours
3. Pain that is present during activity without causing activity modification
4. Pain that is present during all activities and occurs with activities of daily living
5. Intermittent rest pain that does not disturb sleep
6. Constant rest pain that disrupts sleep
Rotatoi cuff teais
Commonly older sports people who present with Sh pain during activity.
Inability to sleep on affected Sh
+ Impingement signs and sometimes weak Supraspinatus m
Confirmed with MRI or Diagnostic Ultrasound
Partial/small tear = Conservative Rx
Full thickness = Surgical repair
In older people, symptoms and level of fx should guide Rx
Glenoid Labrum Injuries
Clinically ielevant anatomy
The Labrum is a ring of fibrous tissue attached to the rim of the glenoid
Wedge shape in cross-section
It expands the size and depth of the glenoid
Also plays a role in proprioception and spreads weight evenly over the interface.
Labral attachment blends directly into articular surface
Occasionally the attachment is meniscoid
- free edge extends into the articular surface and can be mistaken for a tear
Primary attachment site for the capsule and the GH ligts
Tendon of long head of biceps attaches at the superior aspect of the labrum.
Slap lesion: Superior labrum, Ant to post of the biceps tendon tear (Type 1-4)
Stable or unstable according to whether the majority of the superior labrum and biceps tendon are
attached to the glenoid margin
Labral injuries are divided into Type 1-4:
Naking the uiagnosis
The diagnosis depends on an appropriate mechanism of injury, investigation and clinical assessment
Common mechanisms of injury:
Excessive traction on the labrum through the long head of biceps (Superior labrum)
Bankart lesion (Damage to the anterior labrum attachment to the anterior Glenoid margin)
Atraumatic type (Common in pt with Capsular laxity, esp those involved in overhead sports)
Or a Combination (traumatic on an already lax Sh)
Clinical Featuies
Symptoms: Recurrent dislocation/subluxation, Sh pain, dead arm
Pain :
1. From impingement of the rotator cuff tendon, with recurrent translation of the humeral head
This is aggravated by the eventual weakening of the Rot cuff, which in turn fail to depress the
humeral head and results in a Tendinopathy. (Secondary external impingement)
2. May be due to catching of the labral detachment (May be reproduced by Ant drawer test)
Episodes of dislocation and subluxation usually increase in frequency
On examination:
1. Note ligament laxity (Sulcus sign Generalised ligt laxity)
2. Amount of ER
3. Assess m. strength to rule out neurological deficit
4. Tenderness Ant $ Damage to ant structures
Post$ Supraspinatus tear is common with the older pt
5. Which position causes sympt/dislocation (usually Abd and ER)
6. Degree of laxity can be measured with: (If instability, these will cause pain or apprehension)
a. Load and shift drawer test
b. Apprehension-augmentation-relocation test (Greater reliability)
- Apprehension is a better indication than pain
- Sensitise and desensitise b.m.o ant/post pressure
- If the instability is minor and this position does not give apprehension the humeral
head is first anteriorly translated the the arm is taken into Abduction and ER
Investigations
CT and X-ray may be useful in demonstrating associated injuries (Hill-Sachs and Bankart)
MRI Bony lesions, Soft tissue (Labrum), Capsule and Tendons
Tieatment
First time as above. A traditional sling should not be used to manage instability
! Traumatic instability
Arthroscopic Bankart repair is the Rx of choice.
Other structures can the also be repaired (Rot cuff tear, labrum etc.)
Tendon transfer, Magnusson-Stack and Putti-Platt results in loss of ER and is thus not
recommended for sports people
! Atraumatic instability
Intense rehab that involves strengthening of dynamic stabilisers (rotator cuff) and scapular
stabilisers and emphasizing the muscles opposing the instability
If conservative fails $ Surgery for capsular shift
Labral injuries are often associated with Sh instability and must be addressed
Posteiioi Instability
Commonly Atraumatic and part of a Multidirectional instability. Usually there is a + Posterior drawer.
Rx = Strengthening the posterior stabilizing mm, surgery should be considered if these measures fail.
Always keep post labrum in mind with recurrent instabilities (needs surgery if injured too much)
Nultiuiiectional instability
- Combo Anterior; posterior and inferior instability
- Commonly Atraumatic associated with generalized ligamentous laxity throughout the body which
should be assessed at the thumbs, wrist, elbow and knees.
- May also be due to repetitive trauma
On examination:
1. Ant instability : Drawer test and apprehension relocation
2. Posterior instability : Drawer test
3. Inferior Instability : Longitudinal caudate traction = sulcus sign
Pain in mid ranges (Due to translation) is a major characteristic. This indicates a prominent role of
altered muscle activation:
1. # Lower traps and Seratus ant
2. ! Pecs minor and Latisimus dorsi
This leads to scapular protraction and tilting of the glenoid
Relief of symptoms and # translation when placing the scapula in stabilized retraction will point to
the need for an exercise program for scapular and Sh stabilizers (SAT = NB)
No stretching of the muscles around the Sh joint
If this is unsuccessful = Surgical intervention (Not as successful with generalized ligt lax)
Adhesive Capsulitis
GH stiffness is not uncommon after trauma, following injury to the neural structures or occur spontaneously
Adhesive capsulitis (Spontaneous Sh stiffness) occur between 40-60 years of age and affects the L > R with
diabetes being a predisposing factor.
Diagnose by evaluating passive ER ! elbow at side & Scapula stabilized
Normal surgical stiffness resolves within 12 months
Fracture of the clavicle
Fall onto the point of the Sh or direct trauma
Niuule thiiu claviculai fiactuie
Usually # at middle third = Displacement : Outer fragment#, inner fragment!
On exam: Deformity, swelling, local tenderness (extremely painful)
The scapula will assume a protracted position with clavicular angulation or shortening
If conservative Rx the overlapping and shortening should be monitored for 2-4 weeks
Rx:
Mainly to provide pain relief, # heals within 4-6 weeks
Best managed conservatively
Often the clavicle is foreshortened which leads to significant functional deficits
A figure of 8 bandage is designed to prevent foreshortening and has significant theoretical
advantage over a sling or collar
Pt should preform self-assisted Sh flexion to a max of 90 to prevent stiffness
Surgical :
! Open #
! Non-union
! Foreshortening of >1-2cm
Rx:
Self-limiting and resolves in 1.5y
No evidence that physio,
injections or drugs # the outcome
Bistal clavicle fiactuie
May involve disruption of the AC joint and or coracoclavicular ligt
More prone to non- and mal-union
# Med to ligt has greater displacement of fragments = !risk of delayed/non-union if Rx conservatively
Type 1: Rx with sling for comfort, early ROM and isometric strengthening. If displacement is
present, rehab should progress slow and ROM when pain #
Type 2: More controversial as there may be more displacement, surgery often recommended
ICE
Return to sport when full ROM (Pain free) and no local tenderness
Major Fx problems in high grade type3/4 injury is due to the loss of strut function to stabilize the
Scapula, GH joint and arm. 73% of type 3 AC separations lead to an alteration in scapular mechanics
Surgery for type 4,5 and 6 and type 3 that does not respond to conservative management.
aLhology
1ype 1 lracLure dlsLal Lo coracoclavlcular llgL wlLh llule dlsplacemenL
1ype 2a lracLure medlal Lo coracoclavlcular llgL
1ype 2b lracLure beLween coracoclavlcular llgL
1ype 3 lnLra-arucular # wlLhouL dlsrupuon
Chronic AC joint pain
AC joint pain is usually localized over the joint
Symptoms reproduced by: Modified OBreins test
Persistent pain may require distal clavicle excision
Chronic pain may be due to:
1. Repeated minor injuries (maybe following type2/3) which can damage the fibrocartilagenous
meniscus in the AC
2. Osteolysis of the distal end of the clavicle (moth eaten appearance on Xray)
a. Painfull horizontal flexion
b. Impingement due to abnormal scapular position due to loss of strut Fxn
c. Electro, mobilization and strengthening
3. Osteoartheritis (due to recurrent injuries)
a. Osteophite formation or sclerosis on X-ray
Referred Pain
The cervical and upper thoracic spine structures can refer pain to the Sh region
Weakness and wasting of Supraspinatus & Infraspinatus = trapped at the Suprascapular notch
Relative rest
Cryotherapy
#Throwing activities
Meds
Electrotherapy