SHOULDER PATHOLOGIES

RCRSP/ SAPS - etiology

• excessive and maladaptive load

• genetics, hormonal

• traditionally thought that irritation/ impingement caused by subacromial structures (bursa, rotator cuff tendons)

• BUT challenged because predominantly on articular side of tendon

RCRSP/ SAPS - PP

PP

• inflammation

• Overarching term

  • SA impingement syndrome

  • rotator cuff tendinopathy

  • symptomatic partial/ full rotator cuff tears

RCRSP/ SAPS - SS

SS

• pain (99% of patients)

• decrease ROM

• decrease Fx (shoulder elevation, ER)

• painful arc

• +ve hawkins kennedy, Neer’s, empty can

RCRSP/ SAPS - MOI

MOI

• excessive loading

• maladaptive loading

• chronic strain from coracoacromial ligament

Rotator Cuff Tear - etiology

etiology

• injury + weakening of tendon from wear and tear, steroids, smoking

• Age = most common factor

• rotator cuff disease = progressive degenerative process

• Occupation: requiring strenuous overhead activities

Rotator Cuff Tear - PP

PP

• quality of tendon (young, healthy tendons almost impossible to tear)

• acute tears = macrotrauma, often in younger patients

• degenerative tears = typically caused by microtrauma and insufficient healing in older pts

• Cuff tear arthropathy = combination of a massive cuff tear and arthritis of the shoulder joint

Rotator Cuff Tear - SS

SS

• Pain (99% of patients)

• increasing pain and difficulty with overhead activities

  • activities of daily living or carrying heavy objects

  • weakness or pain on exertion

• muscle atrophy

• painful arc

Rotator Cuff - MOI

MOI

• elevated arm forced downward (eccentric force)

• shoulder pain a sudden jerly lift (concentric force)

• acute tear from single traumatic event

• degenerative tear over time due to repetitive microtrauama and insufficient healing

Adhesive Capsulitis - etiology

etiology

• aka frozen shoulder

• idiopathic

• inflammation and fibrotic processes

• secondary to surgical procedures or trauma

• systemic disorders (diabetes mellitus) , thyroid,

Adhesive Capsulitis - PP

PP

• hallmark: shrinking and loss of the synovial layer of the joint capsule

• inflammation

• edema

• thickening of rotator interval and coracohumeral ligament

• decreased capsular volume

• fibrotic process

Adhesive Capsulitis - SS

SS

• intense shoulder pain

  • dull, poorly localized

  • radiates to deltoid area and LHB

• progressive limitation of AROM and PROM in GHJ

• joint stiffness: ER (most), ABD, forward flexion

Adhesive Capsulitis - MOI

MOI

• inflammatory process that leads to fibrotic response

• inflammatory cytokines

  • neoangiogenesis, neoinnervation are present

• Dysregulation of collagen metabolism

OA - Degenerative ( GHOA) - etiology

etiology

• degeneration of articular surface of glenoid and humeral head

• primary or secondary (chronic dislocations, recurrent instabilty, trauma, surgery, avascular necrosis, inflammatory arthropathy, massive rotator cuff tear)

• age = most common non-specific risk factor

OA - Degenerative ( GHOA) - PP

PP

• cartilage loss

• subchondral bony sclerosis

• pain from synovium and subchondral bone

• increase intra-osseus pressure

OA - Degenerative ( GHOA) - SS

SS

• progressive

• increase with PA

• deep within joint

• worsens at night

• mechanical = catching, locking, crepitus

OA - Degenerative ( GHOA) - MOI

MOI

• continuum of effects from specific factors

• ?? abnormal mechanical loading on normal cartilage

• ?? normal mechanical load on abnormal cartilage

• excessive mechanical load

• sedentary lifestyle

GH Instability (subluxation/ dislocation) - etiology

etiology

• traumatic anterior shoulder instability (TUBS)

  • anterior force when shoulder is ABD and ER

• Atraumatic shoulder instability = laxity and loss of muscle control

  • hyperlaxity

  • Ehlers-Danlos Syndrome, Beighton scale ?

GH Instability (subluxation/ dislocation) - PP

PP

• GH joint sacrifices stability for mobility

  • glenoid is more shallow

• Static Stabilizers: GH ligaments, joint capsule, rotator intervals

• Dynamic stabilizers: RC muscles, LGB, deltoid, periscapular muscles

• larger joint capsule

GH Instability (subluxation/ dislocation) - SS

• pain

• multidirectional instability (MDI)

• scapular dyskinesis (winging scapula)

• sulcus test, apprehension, load/ shift test

GH Instability (subluxation/ dislocation) - MOI

MOI

• traumatic = direct anterior traumatic event

  • on an ABD and ER shoulder

• Compression = FOOSH can cause SLAP lesion contributing to instability

• atraumatic = repetitive microtrauma to joint capsule

ACJ Pain (Acromioclavicular joint Injury) - etiology

etiology

• common (40% of shoulder injuries)

• frequent in sporting events

• direct trauma to lateral aspect of shoulder

• Acromion proces with the arm in adduction

ACJ Pain (Acromioclavicular joint Injury) - PP

PP

• synovial joint

• ACJ relies on ACJL and CCL (trapezoid and conoid)

• Mild sprain —> sever disruption

  • can cause loss of strength and fx

ACJ Pain (Acromioclavicular joint Injury) - SS

SS

• anteriosuperior pain

• blunt trauma to the ABD shoulder

• FOOSH

• worsens with movement

• worsens with lying on affected side

• tenderness of palpation

• piano key sign: clavicle elevates and rebounds after inferior compression

ACJ Pain (Acromioclavicular joint Injury) - MOI

MOI

• direct blunt to the lateral aspect of teh shoulder or acromion process

  • usually in ADD

• FOOSH can lead to AC separation

Long Head of Bicep Tendinopathy - etiology

etiology

• anterior shoulder pain often with a history of repetitive overhead use rather than specific trauma

• inflammation/ degeneration (tendinosis, tendinopathy)

• Biceps instability, SLAP lesion

• high association with other shoulder pathologies

Long Head of Bicep Tendinopathy - PP

PP

• termed tendinosis as it is more degeneration than inflammation

• Tendon:

  • swell and discolored as it degenerates

  • thickened, irregular, scarred

• subluxation and dislocation can occur

• compensatory mechanism of LHB overload due to RC instability

Long Head of Bicep Tendinopathy - SS

SS

• pain localized at bicipital groove

• can radiate distally to muscle belly or deltoids

• can be diffuse and vague pain

• popping or grinding

• instability

• Yerganson’ sand Speed’s Test

Long Head of Bicep Tendinopathy - MOI

MOI

• repetitive overhead activities

• Peel-back mechanism: late throwing phase with torsional forces causing bicep to be pulled away from insertion

• frictional stress and damage from bicipital groove morphology

Labral Pathology (Superior Labrum Anterior Posterior Lesions) - etiology

etiology

• multifactorial

• occur following acute events:

  • Compression injuries (FOOSH)

  • traction type injuries (jerking movements or lifting heavy)

• overhead athletes

  • overuse etiologies

  • peel back mechanisms

Labral Pathology (Superior Labrum Anterior Posterior Lesions) - PP

PP

• tear of the glenoid labrum fibrocartilage

  • typically from anterior to posterior

• Severity is split into subtypes based on damage to the labrum and destabilization of the biceps anchor

  • Snyder’s Initial 4

  • Expanded 4 to 10 types

• Vascularity lower in the anterior, anteriosuperior and superior parts of labrum so more vulnerable to injuries and impairs healing

Labral Pathology (Superior Labrum Anterior Posterior Lesions) - SS

SS

• acute onset of deep shoulder pain

• mechanical symptoms: popping, locking, catching

• pain = worsens with heavy lifting, pushing, overhead

• Obrien’s (active comrpession test)

Labral Pathology (Superior Labrum Anterior Posterior Lesions) - MOI

MOI

• Compression: FOOSH, loading labrum directly

• Traction: sudden jerk or lifting heavy objects pulling on the biceps tendon and superior labrum

• Repetitive Overhead Activties: chronic overuse tears via peel back mechanism