Download SHOULDER PATHOLOGIES

SHOULDER
PATHOLOGIES
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)

ROTATOR CUFF TEARS
STAGE 1 STAGE 2 STAGE 3>40yrs
 STAGE 4tears)

reversible edema, <25yrs
fibrosis + tendinitis 25-40yrs
bony spurs + tendon ruptures
shoulder arthropathy (4% cuff
CLASSIFICATION SHOULDER
DYSFNXS
GROUP 1- impingement >35yrs
 GROUP 2- impingement + instability <
35yrs
 GROUP 3- impingement + instability born
loose (have mm control if just
hypermobile)
 GROUP 4 anterior instability torn loose

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 structuresrepeated anterior/superior translation HH
with HF and overhead- shortening post
capsule- undersurface cuff tear- SLAPcomplete RC tear

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)

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

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)
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 stagegeneral
RC TEARS
SMALL TEARS- often missed in young
people, only picked up when, despite
other S&S improving, lat rot remains weak
 LARGE TEARS- generalized weakness and
night pain

ROTATOR CUFF TEARS
3 SIGNS:
1. POSTERIOR CUFF TIGHTNESS
2. EXT ROT 90/90 WEAKNESS
3. SCAPULAR DYSRHYTHMIA
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
ROTATOR CUFF TEARS:
MISINTERPRETATION
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
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)

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
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….
SLAP- HOW??
-
Repeated eccentric biceps contraction
(deceleration)
-
TESTS:
O’BRIENS
CRANKS
1.
2.
Arthroscopy confirms it
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

SLAP LESIONS- S&S


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
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?
SLAP LESION TESTS
RELOCATION TEST- 90/90 pain incr w ext
rot and pa on HH
 ACTIVE COMPRESSION TEST/O’BRIENS90 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

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

CALCIFYING
TENDINITIS/BURSITIS
Pain over deltoid area
 Arc of pain
 Decr ROM
 Night pain
 Atrophy
REST, NSAID, AVOIS IMPINGEMENT
POSITIONS, GENTLE ROM, AVOID HEAT

GENERAL
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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/catching, dead arm:
INSTABILITY OR LABRAL TEAR
Crepitus- RC and AC joint
Grinding- OA
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
CERVICAL SPINE
C4-6
 ULTT
 MOBILITY AND HEAD POSITION
 LEV SCAP!
 R1 AND SCALENAE!
 TX SPINE AND COSTOVERT!!!

QUICK ESCAPE NO TRANSLATOR
1.
2.
3.
4.
5.
6.
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
QUICK ESCAPE NO TRANSLATOR
1.
2.
3.
4.
5.
6.
Release and needle mms
Stretch capsule
Mobilize Tx and Cx if needed
Strap- various ways
Setting of scap, turning on cuff ex’s and
core stability ex’s (NO RESISTANCE OR
LARGE MVTS!), neck stretches
Kinetic handling!!!!!!!!!!!!!!