Shoulder Girdle Pathology

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Shoulder Pain:

Fractures of the shoulder girdle complex

Clavicle: 75% occur in children under 13• Proximal fracture

– Rare, differentiate from epiphyseal injuries

• Middle Third fracture- Most common, 80%– Usually displaced upward by

pull of the sternocleidomastoid muscle

• Distal fracture– Displaced downward by the

weight of the arm.

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• MOI: – Fall on the lateral aspect

of the shoulder

– Fall on outstretched arm (FOOSH)

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• RX: – Arm sling

• For the first 1-2 weeks • To support the weight of the

arm.– Figure of eight

• Figure of eight bandage, intent is to reduce the motion at the fracture site.

• Worn for a period of at least 6 weeks (adults) or 4 weeks (child).

• Can use the arm as wanted & symptoms allow.

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Scapular Fractures

• 1% of all fractures• High energy: fall or direct blow• Associated Injuries– Ipsilateral rib fractures– Pulmonary trauma– Clavicular fractures– Brachial plexus injuries– Subclavian artery injuries

• Classified according to location

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Scapula:• Type I: fractures of scapular

body 2• Type II: fractures of

apophyseal regions including acromion and coracoid process 3,4

• Type III: fracture of superolateral angle including glenoid neck and fossa 1

• RX: generally minimal treatment. Surgery only in most drastic, displaced fractures.

Donatelli RA, 1987

Scapular Fractures requiring surgery

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• Acromion or scapular spine fractures with a doward tilting of the lateral fragment and subacromial narrowing

• Coracoid fractures that extend into the glenoid fossa

• Glenoid rim and intra-articular glenoid fractures associated with glenohumeral instability

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Rx of Scapular Fractures

• Sling 7-10 days• Progressive regimen of pendulum and gentle

ROM exercises• Progressive AROM and strengthening

exercises

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Humeral Head Fractures

Fracture Dislocations

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Proximal: A. Greater Tuberosity

More commonly seen in older individuals.

B. Lesser TuberosityRare, usually avulsion fractures

C. Neck of the HumerusCommon fractures, transverse, comminuted, impacted

D. Shaft of the Humerus

• MOI: significant force applied directly or indirectly to shoulder region

• Rx: depends upon the type of fracture, age of the patient

Fractures Associated with Shoulder Dislocations

Hill-Sachs lesion:– depression fracture of

the posterior/lateral humeral head.

– Area of soft cancellous bone which is compressed against the glenoid rim.

– Occurs in 77% of traumatic anterior dislocations

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http://www.athleticadvisor.com/Injuries/UE/Shoulder/shoulder_dislocation.htm

Bankart Lesion

– Defined as a detachment of the labrum from the glenoid rim, on the anterior

– occur in 87% of the traumatic dislocations

– the most common reason for recurrent instabilities

– Increase rate of reinjury

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www.sportsortho.co.uk/article.asp?article=86

• Quality of the Tissue– Good tissue quality: heal

faster, less functional issues

– Poor tissue quality: will the repair hold, takes longer to heal, more functional deficits after surgery

• Specifics of the Case:– Did it involve the Biceps

Tendon or not?– Removal of any bone?– Other?

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Osteonecrosis

• Snowcap is one of the first signs of osteonecrosis.

• Compression will hurt more as the blood supply is cut off more.

Rotator Cuff Dysfunction Resulting in Impingement

• Key pathophysiological factors– Primary or secondary

impingement– Tensile overload– Macrotraumatic

tendon failure– Posterior or

undersurface impingement

• Key Muscles and Force Couples– Deltoid Rotator cuff force couple

• Deltoid force: Supraspinatus initiator, then deltoid. Therefore if supraspinatus torn, then the shoulder will go straight upand cause impingement. So t(x) will be using other RC to stabilize and how to pull down the humeral head.

• Rotator Cuff force:

– Trapezius and Serratus anterior– Anterior posterior rotator cuff

force couple• Concavity-compression mechanism

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Rotator Cuff Impingement

• Primary Compressive Disease: Primary Impingement– Compression of rotator cuff tendons between the

humeral head and the overlying anterior third of the acromion, coracoacromial ligament, coracoid or AC joint

– Subacromial space• Normals:

6mm-14mm

• Patients with shoulder pain: 7mm-13mm

Neer Classification

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Stage I: characterized by edema, inflammation, hemorrhage in the subacromial space. Swelling is responsible for the impingement – Risk Factors: age 25 or less – SX: dull ache in the shoulder after activity, pain may

interfere with ADL’s

– Start of the cascade

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Signs: painful arc in abduction - between 60 and 120 dg, pain free – PROM, resisted tests are strong but painful for abduction– Palpation: tender over the greater tuberosity and the anterior edge of the

acromian– Special tests: + Neer impingement test, + Kennedy and Hawkins test.

– This stage is easy to reverse if the person rests from aggravating activities and changes some work or play postures, strengthens weak muscles

– AROM painful arch is always present, but not during passive.

Stage II:

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Characterized by aggravation of the subacromial contents creating a thickness in the bursae and fibrosis of the tendons.

• Risk Factors: 25 to 40 years of age • SX and Signs: similar but increased in intensity from

Stage I • Impairments: more limitation in the PROM and with

Hawkins and Kennedy test there is a catching sensation with the return from an elevated position.

• More difficult to reverse than Stage I

Stage III:

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More complicated: – get a partial or full thickness tendon tear, – changes in the bony configuration of the humeral head

and acromion, – osteophytes

• Risk Factor: 40 years of age or greater • SX: increase in intensity of symptoms, interferes with

daily activities • Signs: AROM more limited than PROM, resisted tests

show weakness in abduction and external rotation

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• X-Rays: cystic changes in the greater tuberosity, underside of the acromian or at the AC joint

• RX: surgery if conservative treatment doesn’t work. Repair of the torn muscles would occur with all of the surgical options.

• Surgical Options: 1. coracoacromial ligament resection

2. anterior acromioplasty 3. distal clavicle resection (Mumford procedure) 4. AC joint inferior osteophyte resection

Mechanical Impingement:• Abnormal shape of the

acromion. • 3 types of acromion, flat,

curved and hooked. • There is a close

association with a hooked acromion (70%) with full thickness rotator cuff tears; 80% association with impingement syndrome

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Secondary Compressive Disease

• Due to underlying instability of the GH joint– Anterior instability – overhead athletes, throwing

athletes– Increase in anterior translation, biceps tendon and

rotator cuff become impinged– Continual loss of GH stability– Leads to rotator cuff tears– Usually supraspinatus

Tensile Overload

• Repetitive intrinsic tension overload– Occurs during deceleration

and follow through – High load placed on

posterior rotator cuff muscles

– Pathological changes of angiofibroblastic hyperplasia – early tendon stages, progresses to tears

• Tendinosis injuries– Degenerative process

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Macro traumatic Tendon Failure

• Single traumatic event or a previous traumatic event

• Forces are greater than the tendon can handle

• Normal tendons don’t tear

• 30% damaged to produce a substantial reduction in strength

• Full thickness tears• Bony avulsions• May have had

repeated microtraumatic insults and degeneration over time

• Failure over one heavy load

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Posterior impingement

• Undersurface– In 90 dg of abduction

and 90 dg of Ext rotation– Supraspinatus tendon

and infraspinatus tendon rotate posteriorly and get pinched between the humeral head and the posterior-superior glenoid rim

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• Add anterior translation of the humeral head causes mechanical fraying on undersurface of the rotator cuff tendons

• Halbrecht et al studied baseball pitchers with MRI of shoulder

• Paley et al studied 41 professional throwing athletes – all had this problem

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Rotator Cuff Pathology

• Best management of a tear depends upon:

• Size and duration of the tear, age of the tear, force

that caused the tear.

Massive tear ofSupraspinatustendon

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Rotator Cuff PathologyPartial Thickness (more common) and can involve the superior aspect, the mid-substance of the muscle and the inferior aspect of the muscle.• Incomplete tear• Superior surface or undersurface

of rotator cuff• Superior surface tears: usually

result of subacromial impingement• Undersurface tears associated with

tensile loads and GH joint instability

Full Thickness tears: are pure transverse rupture, pure vertical tear, longitudinal split can occur which parallels the tendon fibers • Entire thickness of muscle is

torn• Initiated in critical zone of

supraspinatus and can extend into infraspinatus, teres minor and subscapularis

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Tear size

• Small Tears: < 1cm• Medium Tears: 1-3cm• Large tears: 3-5 cm• Massive tears: > 5 cm,

tendon is often retracted

• Larger tears are immobilized for longer periods of time

• Compete tear patterns:– Crescent – shaped tears,

don’t usually retract, repaired directed to greater tuberosity

– U-shaped: greatest extent in longitudinal direction to the tendon

• HX: age is 40 years or older with previous shoulder symptoms or injuries

• Acute tears (no previous shoulder problems)– Occur in 5-8% of all rotator cuff tears– Usually associated with trauma– Younger individuals: tear is a result of repetitive forceful use of

arm overhead, • Secondary result from the muscle imbalance, sudden definite injury to

the shoulder. • Rupture in a younger patient usually is an avulsion of the tendon from

the greater tuberosity rather than a tear within the muscle itself

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Supraspinatus Muscle

• Muscle most likely to be implicated in a rotator cuff tear. • 90% are due to structural impingement on the

supraspinatus from the overlying coracoacromial arch. HX: attritional or degenerative tear

Most occur in the posterior region, area near the junction of the supraspinatus and infraspinatus

13-17 mm posterior to biceps tendonAcute injury: FOOSH, abduction movement with

a high force and velocity

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SX: • pain in the lateral aspect of the arm – may radiate in the region of the biceps – rarely below the elbow

• night pain • can’t sleep on the shoulder, • complaints of shoulder weakness

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Signs:• Observation: difficulty elevating arm• AROM: decreased ROM particularly in abduction

PROM: not significantly limited unless a chronic condition or a very painful, acute injury

• Resisted tests: ABD/ER weakness• Palpation: tenderness at the insertion of the muscle at

the greater tuberosity or in the muscle belly

http://www.youtube.com/watch?v=gvhfiuGrESQ35

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Surgery: Basic Information• Repair: try to mimic the

supraspinatus footprint width but not necessarily the size of the original insertion

• Type of Surgery:– Open

– Mini

– Scope

– Other

• Type of Fixation– Anchor?– Placed at 45 dg angle to

resist pull out

– Sutures? How were they used – single row, double row

– Mattress stitch, simple or combination

– Staples – no longer in use http://www.youtube.com/watch?v=Ch2FnzIW7QE&feature=related

Myofascial Dysfunction of the Shoulder Girdle

Chronic shoulder girdle pain or dysfunctionHX: progressive spread of pain, exacerbations,

remissions which are related to activity. Usually affects only one area rather than several as with fibromyalgia.

SX: muscle point tenderness, pain with activity, better with rest

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Signs: absence of joint signs overall decrease in ROM but minimal at first

PROM will equal AROM Swelling over the muscle Crepitus in the muscle Trigger points in the muscle Radiographs, neurological tests and imaging

studies are all normal RX: correct muscle imbalances, trigger point

stretch/spray techniques, pain relief, posture instruct 38

Tendonitis

• Supraspinatus Tendonosis

• Long head of the biceps tendinosis

• Calcific tendonitis

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Musculotendinous Dysfunctions of the Glenohumeral Joint

Tendonitis Rotator Cuff Tendonitis: inflammation of any of the four rotator cuff muscles, most common is the supraspinatus tendon

HX: overuse syndrome, occurs most often with overhead activities

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SX: acute: severe pain, not well localized chronic: low-grade aching,

• fatigue sensation, localized to the lateral aspect of the upper arm or deltoid• difficulty sleeping on the Arm,• catching sensation with the arm in flexion or internal

rotation

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Signs: – AROM: pain with active abduction, external

rotation painful arc: 70 to 120 dg elevation– PROM: full, painfree except in acute stages where

there may be pain due to swelling and causing an impingement

– chronic: IR/ER may be slightly limited with pain

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– Resisted Tests: Supraspinatus: weak and painful. Pain without weakness: more acute tendonitis Pain with weakness: partial tear in the tendon

– Special tests: • Neer + impingement test • Hawkins and Kennedy + impingement test • Supraspinatus test: empty can test• + Lift off test indicates subscapularis

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RX:

• Conservative at first, may use anti-inflammatory medication

• PT: cross friction massage over the tendon, modality use, look at body mechanics and muscular imbalances to help decrease strain on the tendon.

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Physician treatment or surgery

• Arthrogram and MRI are the diagnostic tools, • Surgery will be an acromioplasy, • Release of acoacromial ligament or a

bursectomy. • Surgery usually occurs with chronic cases

only.

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Biciptal Tendonitis: • second most common site of tendonitis in the

shoulder. • Affects the intra-articular portion or close to the site

of its origin as it passes through the bicipital groove, or at the groove.

• Intra-articular bicipital tendonitis with supraspinatus tendonitis cn occur.

• In the groove, the biceps tendon can sublux and causes fraying and swelling of the fibers and the tendon sheath

Causes:

eccentric over loading due to deceleration of the elbow repeated elbow extension repetitive overhead use

HX: no specific history, repetitive overhead activities, occasionally a single event or trauma will cause the problem

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SX: pain with activity, decreases with rest, initially can be quite painful and will later decrease overall

Signs: AROM and PROM show normal range with only a slight limitation of range in passive ROM abduction and IR are limited secondary to pain

• Resisted tests: shoulder flexion, elbow flexion, supination will all be painful, can be strong or weak depending on the condition of the tendon

• Palpation: tender over the bicipital groove

• Special tests: speed’s test is + Yergason’s test is +

RX: initially is conservatively with PT Physician: corticosteroid injection, surgical: decompression of the acromial arch, excision of the transverse humeral ligament

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Calcific Tendonitis

• Deposition of calcium into the tendon• most common tendon is the superspinatus• Found in the avascular portion of the tendon. • Deposits may be a result of pressure at the avascular

region or with a decrease in the O2 supply. • Tenocytes transform into chondrocytes and lay down

calcium deposits • Self Healing: has cycles of deposition and absorption

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Chronic phase: calcium deposits are being laid down

Acute phase: deposit ruptures into the bursa or is absorbed by the tendon

SX: occurs when the deposits are large enough to cause an impingement with abduction or flexion pain with absorption which lasts 3-4 days, excruciating when present

http://www.youtube.com/watch?v=tH24rATG2NY&feature=BFa&list=ULPjEoBbooGuw&index=5

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Neurological Dysfunction:

Thoracic Outlet Syndrome Definition: entrapment syndrome

caused by pressure from the structures in the thoracic outlet on fibers of the

brachial plexus or subclavian artery. Symptoms can be either vascular or neural.

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Risk Factors:

Structures affecting the pathway of the brachial plexus or subclavian artery

– Width of the first rib

Structures affecting the diameter of the tunnel based on congenital factors

a. size of the transverse process of C7 b. length of the clavicle c. presence of a cervical rib

-also caused by a clavicle fracture and resulting mal-union.

Diameter of Tunnel

• Structures which affect the diameter of the tunnel due to trauma suffered in the past or from an injury that just preceded the onset of symptoms.

a. fracture of the clavicle b. callus formation following a fracture of the clavicle or first rib c. degenerative hypertrophy of an arthritic glenohumeral joint

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Functional Changesa. mobility of the AC or SC joints

b. first rib position as a result of posture

c. clavicular position in relation to the

neurovascular bundle

Muscular Factorsa. Scaleni musculature:

hypertrophy, trauma, inflammation b. pectoralis major and

minor c. post traumatic scarring

of the cervical fascia

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Nerve Factors

a. nerve root entrapment b. nerve trunk entrapment c. nerve branch entrapment

Vascular Components• blood vessel

compression: results in vascular congestion which has an immediate effect on pressure within the thoracic outlet region

Pathology

• Chronic compression of nerves and arteries between the clavicle and first rib or impinging musculature resulting in edema and ischemia in the nerves.

• Will get a neurapraxia in which the axons are preserved but segmental demyelination occurs.

• With the loss of myelin, the axons are more vulnerable to compression and it can progress to a loss of axon continuity.

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Thoracic Outlet Syndrome is composed of three subsytems

SCALENUS ANTICUS SYNDROME: entrapment of the neurovascular bundle between the scalenus anterior and a cervical rib.

• (< 1% of the population have a cervical rib and of these only 10% develop TOS)

• Could also be entrapped by an incomplete cervical rib or an elongation of the C7 TP.

• Decreases the floor of the posterior triangle and relocates the plexus and the subclavian artery forward and up against the posterior border of the anterior scalenus

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• SX: pain, tingling sensation, may be cold distally if the artery is compromised. Overhead activities may relieve the symptoms. – Puts scaling at rest to relieve pain, so pt. will but hand over

head.

• Signs: forward head posture, Positive shoulder abduction test (scaleni relief test), Positive Adson’s=looking towards, deep breath, pulse disappearing is a positive Adson’s , Positive Allens Test=looking away, deep breath hold, pulse disappears is a positive allens

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COSTOCLAVICULAR SYNDROME

• Depression of the shoulder girdle and fixation of the clavicle down and back toward the first rib.

• Will decrease the space behind the clavicle

• SX: pain, tingling sensation, pain with overhead activities

• Signs: Positive costoclavicular test (military posture)

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HYPERABDUCTION SYNDROME

• Occurs between the pectoralis minor and coracoid process of the scapula

• SX: pain, tingling sensation, difficulty doing overhead activities

• Signs: Positive Roo’s test =hands up, over-head squeezing for 45 sec tingling.

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Treatment for all syndromes:

• Conservative, will have to correct posture

• Mobilize clavicle, first rib

• Stretch the scaleni and pectoralis minor muscles

• Strengthen the posterior scapular musculature

• Look at work and play posture and activities63

Brachial Plexus Injury: Burner, Stinger

MOI: A. lateral flexion, rotation, and

extension of head to one side

B. hyperflexion of neck

C. lateral flexion of the head and neck to one side and compression of the head toward the shoulder

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Kuhlman, McKeag. 1999

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SX: c/o severe sharp pain, burning in the shoulder accompanied by paresthesia

Signs: sensory changes, absent DTR, pronounced weakness in the deltoid and biceps

Three Grades for a stinger

1. Normal EMG, symptoms are short, last from 30-60 seconds to 2 weeks in duration

2. +EMG, uncharacteristic wave form noted on the EMG, symptoms last from 2 weeks to 1 year

3. + EMG, permanent residual effect on the patient, Symptoms last greater than 1 year

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Labral Tears:

• Shear forces on the GH joint. – A traction stress of the biceps tendon at the

attachment of the superior labrum caused by a high deceleration force applied to a slow rate of elbow extension (throwing).

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Types of tears

a. Radial tear –depth tearb. Longitudinal tear- goes with the labrum aroundc. Bucket handle tear-fray outd. Degenerative teare. Labral frayingf. Avulsion injuries:g. SLAP lesion: superior labrum anterior to posterior

tear

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Forces involved

a. Anterior dislocation= anterior labrum (Bankhart) is torn with forceful abduction, extension and external rotation

b. superior labrum usually has degeneration and fraying occur

c. inferior labrum tear caused by instability, degenerative, or subluxation/dislocation of the shoulder

d. posterior labrum tear caused by a posterior force along the long axis of the humerus when the shoulder is in 90 dg flexion and minimal adduction.

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Symptoms

SX: • clicking • popping • catching in the joint with quick movements

-only causes pain when stressed

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Signs

• Passive and AROM are full, generally painfree but there may be a painful click somewhere in the range – Resisted movement of shoulder abduction to 90 dg and

external rotation will be weak– Positive Clunk test or Positive SLAP test – Palpation: generalized tenderness, may be accurately

localized to the anterior or posterior regions– Joint Play: increased in either the anterior or posterior

direction compared to the other side

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SLAP Repair

Animated version• http://www.youtube.com/w

atch?v=cOWedbzcIWI&NR=1

SLAP Repair surgery• http://www.youtube.com/w

atch?v=TTD6mcLd_7g&feature=mfu_in_order&list=UL

Adhesive Capsulitis

(Frozen Shoulder): chronic capsular inflammation with fibrosis of the capsule, painful stiff joint, thickening and tightness of the joint capsule

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www.eorthopod.com

Etiology is generally unknown, there are theories as to why it occurs

a. primary adhesive capsulits, spontaneous,

unknown stimulus causes a change in the joint capsule b. secondary: due to a disease process such as

diabetes (very high correlation) and/or proceeded by trauma or overuse2)

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Risk Factors:

– Female greater than males

–40-60 years of age

–Usually occurs in the non-dominant hand

Stages of Adhesive Capsulitis

Pre-Freezing Stage– Duration of symptoms < 3 months– Pain with active and passive ROM– Limitation of forward flexion, abduction, internal

rotation and external rotation– Exam: under anesthesia: normal or minimal loss

of space– Arthroscopy: diffuse glenohumeral synovitis

(inflammed) – Pathological changes

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Freezing Stage• Duration of symptoms: 3 months to 9 months• Chronic pain with active and passive ROM• Significant limitation of motion

– Capsule has shrunken, and limiting motion.– ER will be severely limited, but all directions will be limited to

some extent. • Exam under anesthesia: no change in ROM from when

patient is awake• Arthroscopy: diffuse synovitis, tight capsule with

rubbery or dense feel to insertion of scope• Pathology: hypertrophic and hypervascular synovitis.

Subsynovial scar, firbroplasia and scar formation occurring in the capsule

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Frozen Stage• Duration of symptoms 9 months to 15 months• Minimal pain except at end ROM• Significant limitation of ROM with tissue stretch end feel• Exam under anesthesia: ROM identical to when patient is

awake• Arthroscopy: no hypervascularity seen, some remnants of

fibrotic synovium (“remains of a wildfire” -burnt out), diminished capsular volume

• Pathology: burned out synovitis without significant hypertorphy or hypervascularity, capsule shows dense scar formation

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Thawing Stage

• Duration of symptoms: 15 months to 24 months

• Minimal pain• Progressive improvement in ROM• No other data available

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RX:

Medical: closed reduction manipulation uder general anesthesia, PT will get involved in the recovery room and early, fast intervention as an outpatient

PT: painfree ROM, stretching at end range of movement, joint mobilization etc.

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Important to note that most adhesive capsulities patients will resolve without any medical intervention but the process is considerably lengthened. Without therapy, the process may be as long as 1-2 years, with therapy can be limited to 6 -9 months on an average

http://www.youtube.com/watch?v=dCUEbH-vA7k&feature=BFa&list=ULPjEoBbooGuw&index=6

Glenohumeral Joint Instabilities

• Major Issues– Find out age and MOI, as there are age norms.

• A normal shoulder should not dislocate.

– Congenital Joint Laxity, Muscle Weakness, or Anomalies versus Instability

– Joint Structural Faults – SLAP, Supraspinatus tear– Instability classified

• Frequency – how often does it occur• Magnitude – minor trauma causing dislocation or major which might

cause fractures• Direction – unidirectional (anterior, posterior, inferior), bidirectional or

multidirectional• Origin - MOI

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Instability Classification

Traumatic• Etiology: Single force, joint

overloads and humeral head is forced out of the joint

• TUBS: Traumatic Unidirectional instability with a Bankart lesion that responds well to Surgery– Going to be an Anterior

dislocation as it is Bankart

Atraumatic• Patient with multiple joint

laxities• Frequent episodes of subluxation• Lack of motor control• Minor injury results in a

dislocation• AMBRI: Atraumatic

Multidirectional instability that is Bilateral and the primary treatment is Rehabilitation not surgery, if surgery – usually an Inferior capsular shift

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Clinical Concerns

• Scapular Muscle Imbalances/Control– Muscle fatigue– Poor firing rates

• Functional Instabilities– Certain positions or

actions cause the joint to dislocate

– Voluntary dislocations– Involuntary dislocations

Anterior: – Direct force is applied posterior pushing the

humeral head forward over the glenoid fossa

– Most common of the unidirectional

– Younger adults

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Types of Anterior Dislocations:

a. Subcoracoid dislocation: – humeral head is anterior to the glenoid fossa– inferior to the coracoid process– most common of the anterior dislocations

b. Subglenoid: – Head of the humerus is anterior to and below the glenoid

fossa. – Second most common dislocation

86

c. Subclavicular: – head of the humerus lies medial to the

coaracoid process– inferior to the clavicle – Rare dislocation

d. Luxatio erecta dislocation: rare-head of humerus jabbed into ribs and stuck.– arm is fixed in a position of complete

elevation – the humeral head dislocated anterior

and inferior

e. Intrathoracic: – head of the humerus is driven between

the ribs and into the thoracic cavity. – Rare dislocation

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Posterior:

Causes: direct blow to the anterior aspect of the shoulder. – FOOSH injury with the elbow locked into extension.

– Causes can include seizures, electric shock, diving

– MOI: forced adduction with internal rotation and some degree of elevation Incidence: 1-4% of all dislocations

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Inferior & Multidirectional Instabilities

• Shoulder instability with more than one direction of laxity noted in the shoulder capsule.

• Significant inferior laxity combined with either a posterior or anterior translation.

• Causes: – excessive ligament laxity – repetitive activities at extremes of motion– cumulative effect – macrotrauma to the shoulder

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Other aspects of dislocations: 1) often get a second degree rotator cuff tendonitis with radiating pain and paresthesia 2) treatment initially is nonsurgical and conservative rehabilitation 3) surgical treatment

a. inferior capsular shift b. laser surgeries

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4) Age Related Treatment– Patient 20 years or younger: immobilize up to 6

weeks following a dislocation – Patient 20 to 40 years: immobilize 2-3 weeks or

until the pain subsides, usually in 7-10 days

5) Treatment exercise: strengthen internal rotators and anterior shoulder muscles following immobilization for anterior dislocation

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Other lesions associated with dislocations

1) Bankart lesions

2) Hill Sachs lesion

3) Brachial plexus stretch injury: axillary nerve commonly affected

4) Fracture glenoid rim: 73% ranging from a mild chip fracture to a severe fracture

5) stretching or rupture of the axillary or posterior humeral circumflex artery

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Bankart lesion• http://www.youtube.com/w

atch?v=YUDTBjf-f48&feature=related

Glenohumeral Joint Degeneration

• Refer to previous lectures and class notes for discussion on osteoarthritis

• http://www.youtube.com/watch?v=ihNchRSpKag&feature=BFa&list=ULPjEoBbooGuw&index=13

• http://www.youtube.com/watch?v=dIwAGWjWrbI&feature=autoplay&list=ULPjEoBbooGuw&index=7&playnext=1

• RX: if humeral head is involved, surgery may be a prosthetic replacement of bone

• Types of shoulder replacement– Constrained– Unconstrained 94

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• RX: if humeral head is involved, surgery may be a prosthetic replacement of bone

• Types of shoulder replacement– Constrained: cemented in– Unconstrained: no cement. – Reverse: humerus is the cup and socket is a ball. • Differences, but 60 to 80% of f(x) is maintianed.

Rheumatic Diseases:

• Ankylosing Spondylitis, Systemic Lupus Erythematosis, Reiter’s Syndrome, Gout, Rheumatoid Arthritis can all affect the shoulder joint.

• Often these patients are on high doses of corticosteroids and can get asceptic necrosis of the humeral head (snow-cap of humeral head) also increase risk of tear in muscles, tendons. – Higher number of shots, more likely to tear. Normal is 2-3

per year.

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SX: joint pain, tenderness to palpation, effusion, warmth and stiffness, progressive atrophy and dysfunction

Signs: varies depending upon the disorder. Radiographic Signs: osteoporosis near the articular surfaces, uniform narrowing of the joint space, marginal eroisions

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RX: Surgery can include any of the following: synovectomy, acromioectomy or acromioplasty, total shoulder replacement, arthrodesis (surgical fusion of the joint)

For a shoulder joint replacement, what do they want to see on the medical imaging? -Good bone density

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Sternoclavicular Joint Pathology

Sprain, subluxation or dislocation: MOI: – fall on outstretched arm • arm in flexed/adducted • extended/adducted positions

– MVA – Sports Injuries

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Classifications

• Type I: sprain of SC ligaments

• Type II: subluxation of SC joint with possible capsule, disk or costoclavicular ligaments– Type IIA: anterior – most

common– Type IIB: posterior

• Type III: Dislocation– Type IIIA: anterior

dislocation– Type IIIB: posterior

dislocation• Emergency potential if it

involves the subclavian artery located here.

• Type IV: habitual dislocation

Hypomobility of SC joint:• Definition:

– Injury to any part of the shoulder complex can interfere with the SC joint and lessen/change movement

• MOI: FOOSH • SX:

– may be none– slight, vague feeling of discomfort localized to the SC joint region

• Signs:– Look at symmetry, to pick up differences. – loss of movement in either elevation, depression, protraction or retraction

when compared to the other side – may be tender over the SC joint to palpation – Capsular pattern present: pain at end range of glenohumeral elevation,

pain is located at the sternum • Can POP the SC joint and get a lot more motion.

101

Acromioclavicular Joint Pathology:

Sprain or separation: occurs frequently in the AC joint – Accounts for 12% of all dislocations of the shoulder

girdle. – Most frequently injured joint in the body

102

103

MOI:

Trauma: – Downward directed force applied to the

edge of the acromion process (direct blow)

– Fall onto the shoulder with the arm adducted

– Fall onto outstretched hand– Weight lifting bench press

Classification of AC joint sprains

Type I: intra-articular trauma to the AC without disruption of the ligament

• First degree sprain• Mild force caused the

separation at the joint

• SX: minimal pain / localized tenderness at the AC joint,

104

Type I

• Signs: – Resisted Abduction painful– High, painful arc of motion

• Radiograph: – minimal widening of the AC joint space or

coracoclavicular distance – stress radiographs are normal

105

Type II:

• Acromioclavicular ligament is torn but the coracoclavicular ligament is intact.

• Occurs with moderate force.

• 2nd dg or 3rd dg AC ligament sprain, 1st dg Coracoclavicular ligament sprain.

• Capsular tear noted

106

107

Type II, AC joint sprain

• SX: – Superior or posterior

prominence of the distal clavicle

– pain with active ROM – moderate to severe pain

in intensity

• Signs: – Localized swelling, – Moderately tender to

touch – Decreased strength in

the deltoid and trapezius muscle

Type II

• Radiograph: – Widening of the AC joint by 1-1 ½ cm. – Minimal if any increase (max. of 25%) in costoclavicular

space

108

Type III:• AC ligament is torn.

– Coracoclavicular ligament is torn (both Conoid and Trapezoid).

– Severe force, – Capsular damage occurs– 3rd dg AC ligament sprain and

Coracoclavicular ligament sprain.

– Deltoid and trapezius are torn at the distal end of the clavicle

109

Type III• SX: – Patient holds arm in a protective posture of adduction and

internal rotation

• Signs: – Obvious joint deformity: step noted– Clavicle appears to be displaced superiorly– Swelling – Tender to touch – No strength in the deltoid and trapezius muscles

110

Type III

• Radiograph: –Widening of the AC joint 1.5cm or greater –50% or more increase in the

coracoclavicular distance –AC joint dislocation

111

Type IV:

Similar to type III, clavicle displaces posteriorly and is embedded into the trapezius muscle.

112

Type V:• Similar to type III– Increase displacement of

the clavicle superiorly– Deltoid and Trapezius

muscle damage is greater.

– The Coracoclavicular space is greater than 100% difference from the opposite side

113

Type VI

• Significant trauma, rib fracture, nerve injury and vascular compromise.

• Shoulder has a flat appearance, – Clavicle is inferior to the

acromion– Decrease in the

coracoclavicular space.

114

Acromioclavicular Degeneration

OA is common in the AC joint. A decrease in GH joint mobility will lead to an

increase in the movement of the AC joint. • SX: tender to palpate, painful with overhead

movement

115

• Signs: Pain during passive abduction from 90 dg to 180 dg. – Pain during passive horizontal adduction. – Resisted tests are negative unless the joint is inflamed. – Possible crepitus noted with passive dorsal-ventral AC joint

gliding – Possible painful arc due to an inferior AC osteophyte (spur) – Positive O’Brien test

116

• Radiographs: osteophytes noted on x-ray, sclerosis of bone

• RX: arthroscopic arthroplasty– Mumford procedure – Partial Acromioectomy

117a. Large osteophyte, b. Clavicle, c. Subscapularis muscle, d. Acromian, e. Deltoid muscle