SHOULDER PATHOLOGIES

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SHOULDER PATHOLOGIES
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IMPINGEMENTS

• PRIMARY- outlet obstruction (AC osteophyte,
  thickened bursa esp in RA, swelling/Ca deposits
  on RC tendon, humerus, hooked acromions)
• SECONDARY- instability or muscle weakness
  (capsular lax/tightness, mm fatigue, imbalance
  force couples, spinal stiffness)

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ROTATOR CUFF TEARS

• STAGE 1- reversible edema, lt25yrs
• STAGE 2- fibrosis tendinitis 25-40yrs
• STAGE 3- bony spurs tendon ruptures gt40yrs
• STAGE 4- shoulder arthropathy (4 cuff tears)

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CLASSIFICATION SHOULDER DYSFNXS

• GROUP 1- impingement gt35yrs
• GROUP 2- impingement instability lt 35yrs
• GROUP 3- impingement instability born loose
  (have mm control if just hypermobile)
• GROUP 4 anterior instability torn loose

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IMPINGEMENTS

• DEEP IMPINGEMENTS inside of mms impinged, try
  relocation test, if pain improves, then likely
  deep/SLAP. More likely to result in eventual SLAP
  lesion.
• weakening and laxity anterior structures-
  repeated anterior/superior translation HH with HF
  and overhead- shortening post capsule-
  undersurface cuff tear- SLAP- complete RC tear

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IMPINGEMENTS- TESTS

• NEERS- forced elevation of humerus whilst holding
  other hand on top shoulder girdle
• HAWKINS- 90 flexion and forcibly internally
  rotated (support on top shoulder girdle)

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INSTABILITY TESTS

• GROSS
• ANTERIOR INSTABILITY- apprehension
• POSTERIOR INSTABILITY- post instab test
• INFERIOR INSTABILITY- sulcus test
• SUBTLE
• DRAWER- load and shift tests
• ANTERIOR INSTAB- relocation
• INTERNAL IMPINGEMENT- relocation

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ANTERIOR INSTABILITY

• HILL SACHS DEFECT- posterior lateral HH strikes
  rim of glenoid at time of disloc
• BANKHART LESION- avulsion capsule and labrum from
  glenoid (traumatic avulsion)
• Both common with anterior instability
• In 90 abd, incr ext rot, decr int rot (and if int
  rot tight, will use scap protrxn thus vicious
  cycle)

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ROTATOR CUFF TEARS

• STAGE 1- oedema
• STAGE 2- tendinosis
• STAGE 3- tear
• Active mvts such as an arc of pain, HBB and HF
  decr and decr EOR flex are not indicative of one
  or the other stage- general

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RC TEARS

• SMALL TEARS- often missed in young people, only
  picked up when, despite other SS improving, lat
  rot remains weak
• LARGE TEARS- generalized weakness and night pain

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ROTATOR CUFF TEARS

• 3 SIGNS
• POSTERIOR CUFF TIGHTNESS
• EXT ROT 90/90 WEAKNESS
• SCAPULAR DYSRHYTHMIA

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ROTATOR CUFF TEARS MISINTERPRETATIONS

• - ABDUCTION STRONG BUT EXT ROT WEAK Supraspin
  tear (for abd you need deltoid and RC, if strong
  enough, you wont pick it up- RC substitutes)
• INTERNAL ROT- poor test, unlikely
• EMPTY CAN TEST
• ISOLATING EXT INT CUFF MMS

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ROTATOR CUFF TEARSMISINTERPRETATION

• Complex interaction shoulder synergists
• Interdigitation rotator cuff near insertion
• Tear size only really indicated by strength of
  Ext Rot (statically tested, resistance), is
  inversely prop and tests post cuff w no other mm
  substit
• Testing Abd and Int Rot appear to have very
  little clinical value in tears

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RC TEAR- RESISTED STATIC EXT ROT

• STRONG EXT ROT- Rx conservatively
• WEAK EXT ROT- investigate further (ultrasound)
• STRENGTH GOOD, BUT DECR ROM ALL DIRECTIONS-
  frozen shoulder/capsule (COMMON IN DIABETICS)

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SLAP LESIONS

• SLAP SUPERIOR LABRAL INJURIES SUPERIOR
  LABRUM ANTERIOR POSTERIOR
• Biceps tendon also attaches to ant, post sup
  labrum
• Usually SLAP diagnosed by exclusion and
  arthroscopy
• dead arm syndrome weakness and numbness with
  overhead activities

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SLAP- HOW?

• Fall outstretched hand in abd
• Direct blow to shoulder
• TRACTION INJURY
• Subluxation or dislocation
• Repetitive overhead activities
• Lifting heavy objects
• Sudden violent biceps contraction.

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SLAP- HOW??

• Repeated eccentric biceps contraction
  (deceleration)
• TESTS
• OBRIENS
• CRANKS
• Arthroscopy confirms it

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AT RISK FOR SLAP LESIONS

• Ppl with posterior type II SLAP and internal
  impingement pre-injury
• Tight posterior capsule, anterior instability
  with decr int rot, incr ext rot (when doing ext
  rot, biceps in line w labrum, w incr ext rot
  labral disruption occurs, also pinching inf RC
  with the protrxn of the scapula (internal
  impingement).
• TIGHT POST CAPSULE, POOR SCAP CONTROL

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SLAP LESIONS- SS

• GIRD (loss of int rot, incr ext rot)
• SICK scapula (abducted, ext rot, tipped
  anteriorly)
• Instability, RCS, biceps pathology
• Posterior pain
• Incr pain w throwing and lying on it
• Popping, locking, grinding, catching, need to
  move
• ?decr ROM and strength?

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SLAP LESION TESTS

• RELOCATION TEST- 90/90 pain incr w ext rot and pa
  on HH
• ACTIVE COMPRESSION TEST/OBRIENS- 90 flex, 15
  add, int rot, pt flexes and abd against R. Incr
  pain , decr w ext rot..
• CRANK TEST- 90 abd, axial load applied whilst
  slowly taken into int rot. if catching or
  grinding pain

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BICEPS TESTS

• SPEEDS TEST- flex sh against R with elbow
  extended and hand fully supinated
• YERGASONS TEST- sh neutral, elbow 90 flex, resist
  supination from full pronation

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CALCIFYING TENDINITIS/BURSITIS

• Pain over deltoid area
• Arc of pain
• Decr ROM
• Night pain
• Atrophy
• REST, NSAID, AVOIS IMPINGEMENT POSITIONS,
  GENTLE ROM, AVOID HEAT

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GENERAL

• Anterior pain often local pathology
• Posterior pain inside impingement or referred
  from Cx or Tx
• Watch out for distal anaes/paraesthesia
• Pattern of movement gives vital clues
• Slipping, popping/snapping, clicking/jamming/catch
  ing, dead arm INSTABILITY OR LABRAL TEAR
• Crepitus- RC and AC joint
• Grinding- OA

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GENERAL- KIBLER KINETIC CHAIN

• Check your lower limbs, backs, knees, ankles,
  etc. Usually there is a problem in the opposite
  leg to the painful shoulder (esp with medial
  rotation of the hip).
• Check one leg balance, squats, joint ROM LLs,
  core stability etc
• Never forget Lats Dorsi- major reason for decr
  int rot and incr protrxn scap

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CERVICAL SPINE

• C4-6
• ULTT
• MOBILITY AND HEAD POSITION
• LEV SCAP!
• R1 AND SCALENAE!
• TX SPINE AND COSTOVERT!!!

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QUICK ESCAPE NO TRANSLATOR

• Watch undress
• Assess posture- not just shoulder
• Watch carefully bilat and unilat abduction short
  or long lever
• Decide whats weak/hyperactive (remember
  stabilizers and movers)
• Palpate all suspected mms and release
• Test posterior capsule and stretch

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QUICK ESCAPE NO TRANSLATOR

• Release and needle mms
• Stretch capsule
• Mobilize Tx and Cx if needed
• Strap- various ways
• Setting of scap, turning on cuff exs and core
  stability exs (NO RESISTANCE OR LARGE MVTS!),
  neck stretches
• Kinetic handling!!!!!!!!!!!!!!