EVALUATION AND TREATMENT

OF COMMON MUSCULOSKELETAL
DISORDER OF THE SHOULDER
Impingement Syndrome
 Impingement (trapping) of the rotator cuff tendons
under the acromion and the coracoacromial arch,
eventually leading to degeneration and tearing of the
rotator cuff tendon
 It occurs in young active persons
 As a result of repetitive stressful activities such as tennis,
baseball, and volleyball which increase the stress levels
to the rotator cuff tendons
 It also occurs in older person
 As a result of degenerative changes
Impingement Syndrome
Impingement Syndrome
 Because of the relatively poor blood supply near
the insertion of the supraspinatus
 Nutrition to the area may not meet the metabolic
demands of the tendon tissue
 This would result in cell death and inflammatory
response (tendonitis)
 And the body may react by laying down scar tissue or
calcification
 This may cause rupture of the subdeltoid bursa and
result in acute bursitis
Impingement Syndrome
 Swelling would result from
all the inflammation process
(tendinitis and bursitis) and
this would take most of the
subacromial space
 Degenerative changes to the
acromion and/or coracoid
processes may also result in
impingement
Impingement Syndrome
Examination:
 History

 Site of pain: Lateral brachial region, possibly referred

below to the elbow in the C5 or C6
 Nature of pain: Sharp twinges felt on various
movements, such as abduction, putting on jacket, or
reaching above shoulder level
 Onset of pain: Usually gradual with no known trauma.
May be related to occupational or recreational overuse.
May have been present for many months, or even years
 Impingement Syndrome
Examination:
 Physical Examination

 Observation: possible forward head, round shoulder, and/or

flattening of thoracic spine
 AROM: Relatively full ROM. Often a painful arc is present at
midrange of abduction. There is usually slight limitation and pain
at full elevation due to pinching of the tendons between the
greater tubercle and the posterior rim of the glenoid cavity.
 PROM: Essentially full range of motion. Pain at full elevation.
 May be pain on stretch of the involved tendon (e.g., on full
internal rotation in the case of supraspinatus or infraspinatus
tendinitis)
Impingement Syndrome
Examination:
 Resisted movement

 Maximum isometeric contraction of the involved

muscle will reproduce the pain
 In the case of simple tendinitis, the contraction will be
fairly strong; if an actual tear exists, it will be weak
 The supraspinatus is the most commonly involved
tendon
 Others (biceps, subscapularis, teres minor) are rarely
involved
 Impingement Syndrome
Examination:
 Special test:

 Supraspinatus tests
 +ve empty can test
 +ve drop-am test
 impingement tests
 +ve Neer impingement test
 +ve Hawkins-kennedy test
 +ve Posterior internal impingement test
Impingement Syndrome
Treatment:
 Ultrasound

 Decrease inflammation
 increase blood flow to assist the healing process
 May provide some pain relief
 Friction massage: A key component of the treatment
program
 To create mobility in the scar tissue
 The hyperemia induced by the massage may enhance
blood flow to the area to assist the healing response
Impingement Syndrome
Treatment:
 instruction in appropriate use of the arm

 Strict avoidance of activities that may cause

impingement or tension stress at the site of
involvement while painless scar forms
 Gradual return to normal use as healing progresses
 Restrengthening of involved muscles and other
measures to restore normal joint mechanics
Glenohumeral Instability
 Instability may be caused by
weakness of rotator cuff,
damage to the interior
capsule, GH ligament,
and/or glenoid labrum
 Instability can be classified
as
 Traumatic or
 Atraumatic
Glenohumeral Instability
 Traumatic patients exhibit unilateral or unidirectional
instability
 Caused by Bankart lesion
 Injury to the anterior glenoid labrum due to anterior dislocation
 Named after Arthur Bankart, an English orthopaedic surgeon
 Usually required surgery to stabilize the shoulder joint
 Conservative treatment is usually unsuccessful for these
patient
 The successful rate for the conservative treatment for
traumatic patient was found to be only 15% good to excellent
results
Glenohumeral Instability
 Atraumatic patients exhibit multidirectional and
usually bilateral
 Rehabilitation (conservative treatment) is usually
used first
 If conservative treatment fails, then surgery can be
performed
 The successful rate for the conservative treatment
for atraumatic patient was found to be 85%
Atraumatic Instability
History:
 No history of trauma

 Describes symptoms brought on by certain arm positions or

activities
 Can remember since childhood the ability to slip one or both

shoulders out of place with minimal discomfort

 Multidirectional and posterior displacements are more common

 Anterior instability is usually associated with the externally rotated

and abducted arm position
 Posterior instability is manifested with the arm in flexion, internal
rotation, and adduction
 Inferior laxity is usually noted with axial downward traction on the
arm, manifested by a sulcus sign
Atraumatic Instability
Examination:
 Observation:

 No obvious swelling or discoloration

 Sulcus sign: deformity (sulcus) with traction of the arm
 Joint-play movements are considered key tests for the
assessment of instabilities. The amplitude of joint play
(hypermobility) and the presence of pain and muscle
guarding are noted and compared to the other arm
 +ve anterior/posterior drawer test
Atraumatic Instability
Treatment:
 The strength of the rotator cuff muscles is probably the

single most important consideration

 When treating anterior instability
 Rehabilitation should concentrate on the internal rotators and
adductors (pectorals, Subscapularis, latissimus dorsi, anterior deltoid)
 When treating posterior instability
 Rehabilitation should concentrate on the external rotators (teres minor
and major, infraspinatus, posterior deltoid,
 The treatment program should also include exercises to enhance
neuromuscular control
Traumatic Instability
History:
 Significant injury causing a dislocation

 Requiring reduction

 Often subsequent recurrent dislocations

 Apprehension is a common feature in patients with

recurrent dislocations
 Anterior dislocation is more common than

posterior dislocation
Traumatic Instability
Examination:
 Observation:

 Discoloration and swelling may be present

 Shoulder deformity
 +ve apprehension sign
Traumatic Instability
Treatment:
 Usually required surgical repair

 Similar to the atruamtic insatiability, emphasis

should be focused on strengthening of the rotator

cuff muscles for both pre and post surgery
Adhesive Capsulitis (Frozen Shoulder)

 Capsular tightening at
the shoulder
 No specific cause can
be determined for the
stiffening (idiopathic)
 It affects women more
often than men, and
middle-aged and older
persons more often than
younger persons
Adhesive Capsulitis (Frozen Shoulder)

 Some believe that the pain precedes the lose of movement and
that these patient stop using their shoulder because of the pain
 Others believe that the lose of movement precedes the feeling
of pain
 The patient continues to use the arm until the restriction of
motion progresses to the extent that it interferes with daily
activities
 The woman first notices that it is difficult to comb her hair and
fasten a bra
 The man notes difficulty reaching into the hip pocket and combing
his hair
Adhesive Capsulitis (Frozen Shoulder)
 Because much shoulder motion can be lost before
interfering with daily activities of persons in this age
group, these patients do not seek medical help until
the shoulder has lost about
 90° abduction, 60° flexion, 60° external rotation, and 45°
internal rotation
Adhesive Capsulitis (Frozen Shoulder)

History:
 Site of pain: lateral brachial region, possibly referred

distally into the C5 or C6 segment

 Nature of pain: varying from a constant dull ache to pain

felt only on activities involving movement into the restricted

ranges
 The patient is often awakened at night when rolling onto the
painful shoulder
 Onset of pain: very gradual. May be related to minor
trauma, immobilization, chest surgery, or myocardial
infarction. More commonly, no cause can be cited
Adhesive Capsulitis (Frozen Shoulder)

Examination:
 AROM: limitation of motion in a capsular pattern

 ER > abd> IR
 PROM:
 May be limited by pain with a muscle guarding end feel
(acute)
 May be limited by stiffness with a capsular end feel (chronic)
 Joint play: restriction of most joint play movements,
especially inferior glide
 Resisted isometric movements: strong and painless, unless
a tendinitis also is present
Acute vs. Chronic
Acute:
 Pain radiates to below the elbow

 The patient is awakened by pain at night

 on passive movement, limitation is due to

 pain and muscle guarding, rather than stiffness
Chronic:
 Pain is localized to the lateral brachial region

 The patient is not awakened by pain at night

 on passive movement, limitation is due to

 capsular stiffness, and pain is felt only when the capsule is
stretched
Treatment (Acute Stage)
 Relief of pain and muscle guarding to allow early
gentle mobilization
 Ice or superficial heat
 Grade I or II joint-play oscillations
 Maintenance of existing ROM and efforts to gently
begin increasing ROM
 Grade I or II joint-play mobilization. At this stage it is
often best to perform these with the patient lying prone
and the arm hanging freely at the side of the plinth
 Initiation of active assisted ROM exercises at home, such
as wand and pendulum exercises
 Instruction in isometric strengthening exercises
Joint-play Mobilization
Active Assisted ROM exercises
Treatment (Chronic Stage)
 Increase the extensibility of the joint capsule, with special
attention to the anteroinferior aspect of the capsule
 Ultrasound preceding or accompanying stretching procedures
 Specific joint mobilizations, with emphasis on the
anteroinferior capsular stretch (grade IV techniques)
 Instruct the patient in home ROM exercises
 to maintain gains made in treatment and
 to help increase ROM
 Once about 120° abduction, 140° flexion, and 60°
external rotation are achieved, many patients continue to
make satisfactory improvement in ROM by continuing on
a supervised home exercise program
Acromioclavicular (AC) Joint
Sprain
 The AC joint is the
main articulation
suspending the upper
limb from the trunk
 This predisposes the
joint injury
 More common in the
athletic population
Acromioclavicular (AC) Joint
Sprain
History:
 Usually caused by fall on the shoulder with arm at

the side or a fall on the outstretched hand or elbow

 May occur as a result of repetitive overhead

activities (swimming, weightlifting, and body

builder)
 Site of pain: localized pain at the exact site of the

joint
Acromioclavicular (AC) Joint
Sprain
Examination:
 Observation: localized swelling and possible step-off

deformity
 AROM: patient may complain of pain on moving the

arm overhead or across the body into horizontal

adduction
 These movements compress the AC joint
 PROM: pain at end ROM especially with cross-body
adduction
 Resisted motion are usually pain free
 Palpation: localized tenderness over the joint
Acromioclavicular (AC) Joint
Sprain
Treatment:
 Ice to control inflammation

 Arm sling may be used in the acute stage to take

the weight of the arm

 As inflammation subsides (decrease)

 AC joint mobilization

 Pain free ROM exercise

 Scapula stabilization strengthening exercises
 Clavicle Fracture
 Fall onto the shoulder, or
outstretched hand.
 Direct impact to the clavicle

from anterior or superior.

 The fracture is rarely open.

 Clinical features:

 Pain at the shoulder region.

 The patient support the weight

of the arm with the other hand.

 deformity of clavicle
Clavicle Fracture
 Complications:
1- rare, but brachial plexus may
be injured, as may subclavian
artery or vein.
2- Peumothorax.
3- Non-union usually rare,
more likely after internal fixation.
Classification of
Clavicle Fractures

 Group I : Middle third

 Most common (80% of
clavicle fractures)
 Group II: lateral (distal)
third
 10-15% of clavicle injuries
 Group III: Medial third
 Least common (approx. 5%)
Clavicle Fracture
 Intervention
 For most fractures of the
clavicle,adequate treatment
consists of supporting the
weight of the arm in a broad
arm sling.
 In more displaced fractures,
Figure of eight bandage, but
not comfortable.
Clavicle Fracture
 Intervention:
 In sever displaced lateral end
fracture,internal fixation may
be needed.

 A small plate or tension band

wiring may be used
 Cosmotic appearance should
be satisfactory after recovery
 Humeral Shaft Fractures
Fractures of the humerus can be:
 Spiral:

 Caused by twisting injuries of an arm.

 Transverse:
 Caused by direct trauma or a fall onto
the arm.
 Segmented:
 Pathological:
 The humerus is a common site for
metastases and pathological
fractures are often seen
 Humeral Shaft Fractures
Complication:
1. Neurovascular damage:
 The fragments are shaped like spikes and can damage the
radial nerve or the vessels, as well as muscle, as they wind
around the bone.
2. Malunion:
 because the deltoid can abduct the upper fragment without
opposition from other muscles or the weight of the arm.
3. Non-union:
 Soft tissue, including the radial nerve and triceps, can be
caught between the bone ends and lead to non-union
Humeral Shaft Fractures
Treatment:
 Soft tissue usually holds the fragments in

good position and conservative treatment

is generally successful.
 Either a U-slab or a hanging cast will

protect the humeral shaft from additional

trauma and, provided that it is supported
by a sling.
 the weight of the cast applies traction to

the fracture site.

 For pathological fractures, internal

fixation is effective and allows early

mobilization and restoration of function.