Module 2 - Shoulder Pathology

plain film radiographs (X-Ray)?

ionizing electromagnetic radiation of short wavelengths to visualize osseous structures and surrounding soft tissue (limited)

common X-Ray views

- anterior-posterior

- axillary

- internal rotation

- supraspinatus outlet

digital motion X-Ray (DMX)/Fluroscopy

continuous pr pulse X-Ray imaging to capture movement in real time

computed tomography (CT)

rotates X-Ray beam 360 degrees around patient to generate multiple cross-sectional image

magnetic resonance imaging (MRI)

uses strong magnetic fields and radiofrequency pulses to produce high resolution images of soft tissue and bone marrow

arthrography

involves injection of contrast medium into joint to outline intra-articular structures

ultrasound

uses high frequency sound waves to produce dynamic, real time images of shoulder

bone scan (scintigraphy)

use IV injection of a radiotracer to highlighted areas of increased metabolic activity in bone

tendinitis

acute injury with tendon inflammation

treatment for tendinitis

- anti-inflammatory strategies

- protection, activity modification, RICE (rest, ice, compression, elevation)

tendinosis

- abnormal process or degeneration of tendon caused by repetitive microtrauma

treatment for tendinosis

- promoting collagen synthesis, tissue maturation and strength, and not reducing acute inflammation

- eccentric resistance exercise

what are the 3 stages of tendon pathology?

- reactive tendinopathy

- tendon dysrepair

- degenerative tendinopathy

reactive tendinopathy

- triggered by acute overload of tendon where tendon becomes thickened and painful but is intact

- pain with activity and mild loss of function

- common in young adults with abrupt changes in load

tendon dysrepair

- represents an attempt at healing but disorganized collagen and matrix changes

- structural integrity of tendon declines

- symptoms more persistent

- seen with ongoing mechanical overload and inadequate rest

degenerative tendinopathy

- advanced disruption of tendon structure

- symptoms: chronic pain, weakness, functional loss, high risk of tendon rupture

- common in middle to older adults from cumulative microtrauma

primary impingement tendinopathy/tendinosis?

- impingement of RTC beneath coracoacromial arch which results from decreased coracoacromial space and is mechanical in nature and occurs without GH instability

- intrinsic causes (cuff muscles) or extrinsic causes (shape of acromion)

secondary impingement tendinopathy/tendinosis

- occurs secondary to primary problem of instability with anterior or anterior/inferior instability being a key diagnostic criteria

sequence of events for secondary impingement tendinopathy/tendinosis

- initial weakness in biceps and RTC muscles overloads passive mechanisms (ligaments and labrum)

- dynamic stabilizers (RTC and biceps) try to compensate but fail from fatigue

- humeral head undergoes abnormal translation leading to mechanical impingement of RTC

posterior internal impingement

- specific type of secondary impingement that occurs secondary to contact or impingement of articular sides of supraspinatus/infraspinatus tendons

posterior internal impingement commonly occurs in athletes doing what?

OH activities in extreme ER and abduction (baseball players)

describe RTC tears

- in OH athletes and after acute overload events, a vulnerable tendon may fail

- normal aging of cuff tissue characterized by continuous repetitive micro-trauma can predispose tendon for rupture

what is the sizing for RTC tears?

- small

degrees of rotator cuff degeneration

- grade 0: no fatty streaks

- grade 1: some fatty streaks

- grade 2: muscle > fat

- grade 3: muscle = fat

- grade 4: muscle < fat

S/S on RTC tendinopathy (partial)

- painful arc

- pain/weakness in empty can or ER resistance

S/S of calcific tendinopathy?

- acute or severe pain episodes

- painful arc

- night pain

- calcific deposits

S/S of RTC full tear

- night pain

- weakness

- drop arm test

- positive hornblowers

S/S of subacromial-subdeltoid bursitis

- lateral shoulder pain

- painful arc

S/S of long head of biceps tendinopathy?

- anterior groove tendernes

- pain with Speeds or Yergasons

- pain with forward elevation

S/S of long head of biceps instability/SLAP

- deep joint pain

- clicking

- symptoms provoked with O'Briens Tests

S/S of AC Joint Pain

- localized AC tenderness

- pain with cross body adduction

S/S of GH microinstability

- instability symptoms

- humeral head migration

S/S GH osteoarthritis

- stiffness/crepitus

- > 50

- radiographic changes

S/S of cervical radiculopathy

- neck pain

- dermatomal patterns

- Spurlings/ULTT

- provocation/alleviation with compression/traction

S/S of suprascapular neuropathy

- aching posterior shoulder pain with infra-supra atrophy

- ER weakness

proximal biceps tendinosis

- inflammation and tendinosis of biceps tendon

- degenerative condition involved in repetitive activities like throwing, golf, sports with humeral rotation above horizontal

clinical presentation of proximal biceps tendinosis?

- isolated disorder of LH biceps with pain over anterior shoulder and bicipital groove

- pain to palpation over bicipital groove

- pain with contraction and passive max lengthening

- painful arc between 60-120

subacromial bursitis

- acute or chronic inflammation of the subacromial bursa

- repetitIve shoulder movement cause reactive accumulation of fluid within bursa

- often occurs secondary to repetitive activities and linked to impingement and RTC tears

clinical presentation of subacromial bursitis

- onset sudden

- tenderness to palpation over anterolateral aspect of shoulder

- pain with abduction beginning at 60 and decreasing at 100-120

- resisted testing normal

calcific tendinitis

- chronic tendinitis with formation of mineral deposits in and around tendon

- likely a result of tendon degeneration caused by chronic fibrosis and necrosis

what are the 2 phases of calcific tendinitis?

- precalcific: asymptomatic transformation of tendon (formative - calcium deposits in tendon, resorptive - calcium reabsorbed)

- postcalcific: remodeling of collagen

scapular dyskinesis

- symptomatic/asymptomatic change in scapular position of dynamic motion

- 3 subtypes

- can occur from any consequential factor leading to alterations in scapular position/motion

factors cause scapular dyskinesis

- impaired posture

- impaired muscle function

- muscle inflexibility

- proprioceptive dysfunction

3/4 subtypes of scapular dyskinesis?

- 1: at rest, prominence of the inferior medial border

- 2: at rest, prominence of entire scapular border

- 3: prominence of superior border

- 4: normal

scapular dyskinesis test

- unweighted shoulder flexion and abduction watching scapula

- 1-2 lbs shoulder flexion and abduction watching scapula

what are the 3 clinical stages of SA and RTC tendinopathy?

- stage 1: edema & inflammation

- stage 2: fibrosis & tendinitis/tendinosis

- stage 3: tendon degeneration & rupture

describe stage 1: edema and inflammation for SA and RTC tendinopathy?

- age 25 or younger

- consistent with contractile lesion

- anterior/lateral shoulder in C5 distribution

- aching pain triggered by activity (OH and lifting objects out)

- tender over GT

- painful arc between 60-120

- changes typically reversible

describe stage 2: fibrosis & tendinitis/tendinosis for SA and RTC tendinopathy

- 25-40 yrs

- continuation of stage 1 S/S

- increases pain with ADLS, at rest, and night

- increasing tenderness

- worsening pain in C5 distribution

- changes in accessory joint motion

- changes not typically clinically reversible

describe stage 3: tendon degeneration & rupture

- 40+

- increased pain with ADLs, at night

- progressive weakness in abd and ER

- atrophy of muscles

- capsular restrictions and pathological end-feels

- changes not clinically or surgically reversible

how many stages are in Neer's Stages of subacromial impingement?

3

describe stage 1 of Neer's stages of subacromial impingement

- less than 25

- intermittent pain with OH activities

- edema and hemorrhage

- reversible cuff edema

- non-surgical management

describe stage 2 of Neer's stages of subacromial impingement

- 25-40 yrs

- fibrosis and tendinosis

- irreversible tendon changes

- conservative and surgical management

describe stage 3 of Neer's stages of subacromial impingement

- 40+

- significant tendon degeneration

- RTC Tear, biceps tedon rupture and bony changes

- surgical management

what is painful arc special test?

active elevation watching when there is pain

what is Neer Impingement Test?

passive forward elevation with IR at end-range

what is Hawkins Kennedy Test?

passive IR at 90 degrees of flexion

what is empty can test?

elevation or resisted elevation in scapular plane with IR

what is the lift off test?

resisted IR from behind back

what is the drop arm test?

AROM and resisted eccentric lowering

what is the ER lag sign?

resisted hold in ER

what is the Hornblowers sign?

resisted ER in abduction

what are 3 tests that great the best cluster for subacromial impingement?

- painful arc

- empty can

- ER resistance

GH joint instability

- asymptomatic or symptomatic condition characterized by abnormal movement between humeral head and glenoid

- inability to keep humeral head center in glenoid fossa when arm is elevated or placed in certain positions

GH joint subluxation

- symptomatic translation of the humeral head on fossa without complete separation of articular surfaces

GH joint dislocation

- complete loss of articulation of joint

what directions is GH joint instability most common?

- anterior

- anterior/inferior

FEDS classification system

- frequency (solitary 1, occasional 2-5, frequent 5+)

- etiology (traumatic, atraumatic)

- primary direction (anterior, inferior, posterior)

- severity (subluxation, dislocation)

what are the frequency categories for the FEDS system?

- solitary = 1 episode

- occasional = 2-5

- frequent > 5

what are the etiology categories for the FEDS system?

- traumatic: history of injury

- atraumatic: no history of injury

what are the primary direction categories for the FEDS system?

- anterior

- inferior

- posterior

what are the severity categories for the FEDS system?

- subluxation: spontaneous reduction

- dislocation: required physical force

what does hawkins classification scheme for GH joint include?

- frequency

- etiology

- directions

- degree

- volition

what are the frequency categories for Hawkins scheme?

- acute

- chronic

- recurrent

what are the etiology categories for Hawkins scheme?

- traumatic (macrotrauma)

- atraumatic

- microtrauma

- congenital

- neuromuscular

what are the direction categories for the Hawkins Scheme?

- anterior

- posterior

- inferior

- multidirectional

what are the degree categories for Hawkins scheme?

- subluxation

- dislocation

what are the volition categories for Hawkins scheme?

- involuntary

- voluntary

what are capsular tears of GH joint?

results from direct or indirect loading over humerus

what are capsular detachments?

detachment of labrum from direct or indirect loading over humerus

what is the clinical presentation of shoulder dislocations?

- severe acute pain with an overt MOI

- arm is held across body in IR with varying degrees of abduction

what is anterior GH instability?

- most usual form of GH instability

- MOI: traumatic event that places shoulder in extreme abduction and ER

clinical presentation of anterior GH instability

- history of pain and dysfunction associated with instability

- excessive looseness

- atrophy

- humeral head more palpable anteriorly

- positive anterior apprehension, load and shift, and crank test

how do most anterior GH dislocations occur?

- result of axial loading of arm in abducted and ER position, OR abducted, extended, and ER position

what is the greatest risk of injury with an anterior dislocation?

axillary nerve

what is the management of anterior dislocations?

- young: sling for 4-6 weeks

- older: sling for 1-2 to decrease stiffness

what is the rehab progression for anterior dislocations?

- immobilization phase: progressive isometrics

- post-immobilization phase: progressive resistive exercise

what are common associated lesions with a anterior instability/dislocations?

- hill-sachs lesion

- reverse hill sachs lesion

- bankart lesion

- perthes bankart lesion

hill-sachs lesion?

- compression fracture of posterolateral aspect of humeral head

reverse hill sachs lesion?

- compression fracture of anterior-medial humeral head

bankart lesion

avulsion of capsule and glenoid labrum from anterior rim of glenoid

perthes bankart lesion

anterioinferior labrum is torn and lifted from glenoid edge but remains intact to periosteum

how do most posterior GH instability/disclocations occur?

- result from axial loading of arm in adducted and IR position OR adducted, flexed, and IR

- can also occur during electrocution or grand mal seizures

what are the clinical findings for posterior GH instability/dislocation?

- limitations ino elevation above 90

- prominence over posterior shoulder

- flattening of anterior aspect of shoulder

- positive clunk test

- GIRD

what are early interventions for an unstable shoulder?

- education

- immobilization

- rest

- pain control

what are the immobilization recommendations for an unstable shoulder?

- < 20: 6 weeks

- 20-30: 2-3 weeks

- 30-40: 10-14 days

- > 40: 3-5 days

what are intermediate interventions for an unstable shoulder?

- education

- RTC and scapular strengthening

- isometrics

- anterior instability precautions

what is atraumatic instability?

instability without significant or notable injury

what are potential causes of atraumatic instability?

- loss of negative intra-articular pressure

- failure of GH ligaments

- failure of dynamic stabilizers

- altered NM control

- anatomical variations

- disuse atrophy

- familial and systemic factors

what is a SLAP lesion?

injury to the superior glenoid labrum that extends from anterior to posterior relative to the biceps tendon

what are the 4 types of SLAP lesions?

- type 1: degenerative fraying of superior labrum with bicep intact

- type 2: avulsion of superior labrum and biceps from glenoid

- type 3: bucket handle tear with intact biceps

- type 4: bucket handle tear extending into biceps