The Shoulder

Student Learning Objectives

Identify the etiology for rotator cuff tears Describe the clinical manifestations of rotator cuff tears Develop a management protocol for rotator cuff tears Define shoulder instability Differentiate between the dislocators & subluxators Describe the forms of instability

SLOs
Explain the clinical presentation of a

patient with instability and how it should be managed. Describe the MOI for labral tears Cite the types of SLAP lesions, clinical manifestations & treatment Describe the MOI, clinical manifestations, & treatment for AC, SC sprains & capsulitis

Rotator Cuff Tears

History
Typically in 40 + individuals secondary to repetitive activities (degeneration - Neer Stage 3) or younger pt who experiences trauma (hx of repetitive activity that creates degeneration or one traumatic event) Sxs = Pn, esp. w/overhead activities, night pn, weakness, limited motion esp in elevation; rotation may also be limited depending on wear tear is

Examination
Atrophy &/or defects of a tendon in long

standing tears Tenderness over cuff, biceps; edema; tendon defects ROM is limited w/altered scapulohumeral rhythm + Impingement, Codmans, etc. Mm weakness

Special Studies

Radiographs may be negative or show degenerative changes. Possible superior migration of humeral head

Special Studies
Arthrography definitive diagnosis MRI - may or may not show tear

Management - Phase 1 (Pain Control)

Rest Physiotherapy Mobilization Counter force Bracing ROM exercises Strengthening exercises for rotation Full body conditioning

Management - Phase 2 (Restore ROM)

Mobilization ROM exercises (stick or towel) Stretching exercises Pulley/Wall climb/Pendulum

Postural training
Full body conditioning

Management - Phase 3 (Normalize strength)

Isometrics Isotonic strengthening Continue full body conditioning Eccentric strengthening of cuff Isokinetic exercises

Management - Phase 4 (Proprioception)

Proprioceptive retraining (gymball pushups & balance a pole) Progressive resistance exercises Plyometrics (involving vertical & horizontal movements

Phase 5 Sport Specific Training Exercises

Shoulder Instability

Definition

Humeral head may undergo a subluxation or a dislocation. In either case the stabilizing forces may become laxed leading to instability

Etiology/pathogenesis

Acute First-time Dislocation

Indirect - ext rot, abd, ext leverage Direct - traumatic Speed plays a role-ligs are weakest w/rapid

Etiology/pathogenesis
Recurrent anterior subluxation

Acute injury or overuse causing stretching of anterior stabilizers

Recurrent anterior dislocation

Trauma disrupts anterior stabilizers Laxed (multidirectional laxity) shoulder that undergoes minimal trauma

Epidemiology
Shoulder dislocation prevalence 1%-2% Anterior instability accounts for 95% of all

shoulder instability problems Recurrence rate may be 92% Younger the pt at first time dislocation the higher the rate of recurrence Higher incidence in people involved in throwing sports

Types of GH Instability

TUBS (Born Loose)

Traumatic Unidirectional Bankart deformity Surgical

AMBRI (Torn Loose)

Atraumatic Multidirectional Bilateral laxity Rehab helps Inferior capsule may need tightened

Clinical Manifestations
Dislocation - acute pain and deformity

following trauma Instability - humerus may give way, have vague discomfort, apprehension, paresthesias, weakness. Usually occurs in a specific position or action of the arm. Pt may have sx of Impingement, tendinitis, bursitis.

Clinical Manifestations
Possible generalized laxity Dead Arm Syndrome - anterior subluxators

Sharp pain w/extreme external rotation or following a blow to shoulder Immediate loss of muscle strength Pain may subside quickly but strength return may take minutes to hours to days.

Diagnosis
History Inspection - dislocation, atrophy, winging Palpation - point tenderness over GH, AC, SC jts or muscles ROM - diminished or excessive in some ranges, weakness (+) tests for laxity/instability, (+,-) labral tears & Impingement/tendinitis Imaging

Anterior

Inferior

Hill-Sachs
Affects posterolateral humeral head Typically results from impaction of the anteroinferior surface of the labrum on the posterolateral aspect of the humeral head during dislocation.

Bankarts

Detachment of the anterior band of inferior glenohumeral ligament from the labrum.

MRI

Acute
Hemarthrosis Rotator cuff contusion Hill-Sach w/bone marrow edema Torn labrum Torn, discontinuous capsule

Chronic
Intra-articular loose body Hill-Sachs w/o edema Subchondral cysts on head Fragmented labrum Thickened capsule Thinning of articular cartilage

Management
If the GH joint is dislocated, reduction must

be performed. Immobilize after reduction for a few days to weeks depending on whether patient is acute dislocation or recurring subluxator and their age.

Phase 1
Rest Possible use of an immobilizer Pt still goes through wrist/hand rom and early shoulder rom avoiding ext rot, abd & distraction NSAIDs and physiotherapy

Phase 2
Ice, NSAIDs Restoring ROM passively initially Scapulothoracic articulation= protract/retract; elevate/depress

Phase 3
Mobilization to stretch tighten capsule (1-2

weeks post-injury) Perform ROM & strengthening exercises prior to 45 degrees of abd. When strength improves & pn decreases move up higher

Phase 4
Continue ROM exercises Continue Strengthening exercises Initiate proprioceptive retraining

Phase 5
Prepare pt to return to activity Strengthening activity/sport specific Endurance training Speed training - plyometrics

Phase 6
Return to sport Continue to work on any strength or

functional deficits.

If shoulder remains unstable:

Activity modification for those who have

instability with certain activities (sport) and willing to give up the sport Surgery for those who are unwilling to modify activities or who have instability during their ADLs

Surgery
Evaluate the full extent and direction of instability under anesthesia (mm are relaxed) Arthroscopy capsule, ligaments tightened Open Surgery structures are repaired, reattached &/or tightened Rehab = ROM of elbow, wrist, hand day after; most can write & eat w/in a week; Supervised PT initiated 1-4 wks post-surgical; Full ROM return 68 wks, Strength w/in 3 months; return to play may be 1 yr

Glenoid Labrum Tears

MOI

Excessive traction - inferior or superior traction Compression fall on outstretched arm w/ shoulder in flexion and ext rotation Chronic overuse/age related = instability
SLAP lesion is most common type of labral

tear

SLAP Lesions-extend from ant to post to biceps tendon

Clinical Manifestations
Seen in conjunction w/other shoulder

pathologies Poorly localized pn Exacerbated by overhead or behind the back motions Popping, clicking, grinding, tenderness ROM changes esp over 90 (+) Clunk & other labral tests

Special studies

XRay may be:

Normal Show loose bodies, degenerative changes, Bankart or Hill-Sach, diminished subacromial arch

MRI
Shows defect

Arthroscopy

Management
Similar concepts as with instability rehab. Rest

NSAIDs & physiotherapy for

pain/inflammation ROM Strengthening exercises Possible surgical repair if the patient shows no signs of improvement within 2-4 weeks of treatment.

AC Sprains - MOI
Trauma - elevation, depression, retraction

or A-P translation will injure AC & SC joints Direct - direct downward blow to clavicle or fall on point of shoulder w/arm at side or adducted Indirect - fall on outstretched arm or lateral border of the shoulder

AC Sprains

Two classifications Grades I - III Type I - VI

Grade I
Mild Minimal pain & swelling Tenderness at AC lig No instability Tight Traps

Grade II
Moderate Marked pain, edema, instability Torn capsule & AC lig Painful arc abd, ROM loss, tight traps Possible gapping w/stress films

Grade III
Severe complete separation AC & CC ligaments are torn Pain, tenderness, step defect R/O concurrent fracture

Types I - VI

I: sprain without a complete tear, clavicle is not displaced. II: Complete tear AC lig & partial tear of CC lig. The clavicle is slightly displaced.

III: Complete tear of AC & CC ligs. clavicle is dislocated.

IV, V, VI: Complete tear of AC & CC ligs. The clavicle is severely dislocated & usually requires surgical intervention.

Diagnosis
History Palpation ROM Provocative tests Imaging

Management
Therapy depends on the grade. Rest w/possible immobilization NSAIDs & physiotherpay ROM & strengthening III maybe conservative or surgery

SC Sprains
Not common Three types

I mild pn & edema; Tx w/ice & NSAIDs II moderate pn & edema; ROM is effected; Tx may need a sling or figure 8 harness; possible residual bump at jt ROM exercises for I & II initiated w/10 days

SC Sprains
III complete jt dislocation (anterior or posterior; anterior more common) Anterior reduced; pt supine, w/rolled towel betw scapula, arm is tractioned and abducted while direct pressure is applied to clavicle Posterior dislocation will probably require an open reduction although try closed reduction first Immobilized in a splint for 4-6 wks w/gradual restoration of motion

Adhesive Capsulitis

Definition & Epidemiology

Condition of unknown etiology

distinguished by painful restriction of almost all movements on both active & passive ROM (esp abduction & ext. rot) Affects 2%-5% or population F>M Betw 4th & 6th decades

Etiology
Unknown but causes inflammation &

adhesions Primary (idiopathic) Secondary

Intrinsic - problem in shoulder Extrinsic - problem outside shoulder Systemic disease

Pathogenesis
Synovitis in early stages. Intra-articular adhesions in axillary fold Capsular thickening at coracohumeral & sup gh ligs Fibrosis

Stages
Painful (Freezing) = severe pn, night pn &

gradual loss of joint volume & motion; lasts 10-36 wks Adhesive (Frozen) = pn decreases, ROM loss doesnt change; lasts 4-12 months Recovery (Thawing) = gradual return of motion; lasts 12 months or years

History
Initially a generalized ache that may

radiate Becomes a moderate to severe pain & stiffness Patient reluctant to move arm so difficulty in performing normal ADLs Night pain so sleep loss

Px
Possible atrophy of shoulder girdle mm ROM loss usually follows a capsular pattern of limitation (abd, ext rot first & most, int rot, flex, add, extension) Increased scapular motion Jt hypomobility = GH, AC, SC & lower cervicals

Management
Conservative

ROM exercises NSAIDs and analgesics Manipulation/mobilization of shoulder girdle and other joints as indicated Possible MUA Education - no pain no gain (to a point) Home exercises Physiotherapy for pain control

Management - Allopathic