Case 1: Mike Chiasson

Extension

Increase angle between 2 body parts

Flexion

Decrease angle between 2 body parts

Abduction

Move away from midline

Adduction

Move towards midline

External Rotation

Rotation away from midline

Internal Rotation

Rotation towards midline

Elevation

Move up/superiorly

Depression

Move down/inferiorly

Circumduction

Circular motion

Plantar/Palmar Flexion

Movement towards front/anterior side (down)

Dorsiflexion

Movement towards dorsal/posterior side (up)

Eversion

Move foot sole outward (away from midlin)

Inversion

Move foot sole inward (towards midline)

Pronation

Hands: Palm down + arms at side

Feet: Eversion + dorsiflexion

Supination

Hands: Palm up + arms at side

Feet: Inversion + plantar flexion

Ligaments

Connect bone to bone

Stabilize joint

Tendons

Connect muscle to bone

Transmit force from muscle → bone = Movement

Cartilage

Tissue between joint bones

Cushioning = Absorb + distribute shock

Reduce friction = Smooth movement

Shoulder/Rotator Cuff: Joints

4 joints

• Sternoclavicular

• Acromioclavicular (AC)

• Glenohumeral

• Scapulothoracic

Shoulder: Sternoclavicular Joint

Saddle joint between medial clavicle + sternum manubrium

Ligaments:

• Anterior + posterior sternoclavicular

  • Between manubrium + clavicle

• Interclavicular*

  • Join both clavicle ends

• Costoclavicular*

  • Join first rib + clavicle

Sternoclavicular Joint Movements

Elevtation/depression

Protraction/retraction

Circumduction

Shoulder: Acromioclavicular (AC) Joint

Synovial joint between clavicle + scapula acromion

Ligaments:

• Acromioclavicular

  • Between acromion + clavicle

• Coracoclavicular

  • Between scapula coracoid process + clavicle

AC Joint Movements

None alone

Shoulder: Glenohumeral Joint

Ball-and-socket joint between humerus head + scapula glenoid cavity

Ligaments:

• Coracoacromial

  • Between coracoid process + acromion

• Coracohumeral*

  • Between coracoid process + humerus greater tubercle

• Glenohumeral (superior, middle, inferior)

  • Between glenoid labrum (scapula) + humerus neck

• Transverse humeral

  • Between humerus greater tubercle + humerus lesser tubercle

Bursa: Fluid-filled sacs in synovial membrane reducing friction

Glenohumeral Joint Movements

Flexion/extension

Medial/lateral rotation

Abduction/adduction

Circumduction

Shoulder: Scapulothoracic Joint

Physiological joint

Scapulothoracic Joint Movements

Elevation/depression

Protraction/retraction

Lateral/medial rotation

Shoulder: Bones

2 bones

• Clavicle

• Scapula

Clavicle

Anterior S-shaped bone connecting scapula + sternum

• Above rib 1

Articulation

• Medial/Sternal End: Manubrium (sternum) = Sternoclavicular joint

• Lateral/Acromial End: Acromion (scapula) = AC joint

Scapula

Posterior flat triangular bone

• Above ribs 2-7

Articulation:

• Posterior Surface: Clavicle (acromion)

• Anterior/Costal Surface: Glenoid fossa + humerus head = Glenohumeral joint

Shoulder: Muscle Groups

Scapulohumeral (intrinsic shoulder)

Anterior axioappendicular

Posterior axioappendicular (extrinsic shoulder)

Scapulohumeral Muscles

Rotator cuff muscles

Teres major

Deltoid

Scapulohumeral: Rotator Cuff Muscles

Subscapularis

Supraspinatus

Infraspinatus

Teres minor

Rotator Cuff: Subscapularis

Anterior

Innervation:

• Upper + lower subscapular nn.

Action:

• Shoulder internal rotation

• Arm adduction*

Rotator Cuff: Supraspinatus

Posterior

Innervation: Suprascapular n.*

Action:

• Arm abduction ≤ 15º

• Shoulder external rotation*

Rotator Cuff: Infraspinatus

Posterior

Innervation: Suprascapular n.*

Action: Arm external rotation*

Rotator Cuff: Teres Minor

Posterior

Innervation: Axillary n.

Action:

• Arm external rotation*

• Arm adduction

Scapulohumeral: Teres Major

Posterior

Innervation: Lower subscapular n.

Action:

• Arm adduction

• Arm internal rotation

Scapulohumeral: Deltoid

Innervation: Axillary n.

Action:

• Arm abduction ≤ 90º

• Arm adduction

• Arm extension

• Arm flexion

Anterior Axioappendicular Muscles

Subclavius*

Pectoralis major

Pectoralis minor

Serratus anterior

Ant Axioappendicular: Subclavius

Innervation: Subclavian n.

Action: Shoulder + clavicle depression

Ant Axioappendicular: Pectoralis Major

Innervation: Medial + lateral pectoral n.

Action:

• Arm adduction*

• Arm internal rotation

Ant Axioappendicular: Pectoralis Minor

Innervation: Medial pectoral n.

Action:

• Scapular protraction

Ant Axioappendicular: Serratus Anterior

Innervation: Long thoracic n.

Action:

• Scapular protraction

• Shoulder upward rotation

• Arm abduction > 100º

Posterior Axioappendicular Muscles

Trapezius

Latissimus dorsi

Levator scapulae

Rhomboid major + minor

Post Axioappendicular: Trapezius

Innervation: Accessory n. (CN XI)

Action:

• Scapular elevation, depression, adduction, upward rotation

• Arm abduction > 90º

Post Axioappendicular: Latissimus Dorsi

Innervation: Thoracodorsal n.

Action:

• Arm adduction, abduction, extension*, internal rotation*

Post Axioappendicular: Levator Scapulae

Innervation: Dorsal scapular n.*

Action:

• Scapular elevation

Post Axioappendicular: Rhomboid Major + Minor

Innervation: Dorsal scapular n.

Action:

• Scapular elevation + rotation

Chronic Tendon Disorders: Description

Tendinopathy: Tendon strain

• Tendonitis: Inflammation

• Tenosynovitis: Synovial tendon sheath inflammation

• Stenosing Tenoxynovitis/Tenovaginitis: Tendon entrapment

• Tendinosis: Tendon degeneration without inflammation

• Rotator Cuff Disease/Subacromial Impingement Syndrome: Rotator cuff tendon compression + injury

Tendinopathy: Epidemiology

General risk factors:

• Athletes

• Occupation with manual labour/repetitive movements

• Obesity

• Previous tendon injury

• Fluoroquinolone use*

Subacromial impingement risk factors:

• Overhead sports

• Repetitive arm movements (horizontal/overhead)

• Decreased rotator cuff strength*

  • Stroke

  • Parkinson

Tendinopathy: Etiology

Overuse/overload injury

• Repetitive movements = Strain tendon insertion

Trauma

• Laceration

• Rupture

Tendinopathy: Pathophysiology

1. Repeated skeletal muscle contraction = Repeated tendon strain = Tendon microtrauma

2. Improper tendon healing = Tendinopathy

• Tendinotitis + Tenosynovitis: + inflammation

Tendinopathy: Impingement Syndrome Pathophysiology

Narrowed subacromial space

Intrinsic: Rotator cuff causes

• Tendon overuse = Trauma = Tissue degeneration

Extrinsic: External rotator cuff causes

• Mechanical tendon compression by external structures = Tissue degeneration

Tendinopathy: Clinical Presentation

Localized pain/tenderness

• Worse with movement

• Nocturnal exacerbation when lying on shoulder

Inflammation + swelling

Decreased function

• Restricted movement

Tendinopathy: Investigations

Clinical diagnosis

Provacative tests (clinical exam)

Power assessment

Imaging

Tendinopathy Investigations: Provacative Tests

Impingement syndrome:

• Neer test

• Hawkins-Kennedy test

• Painful arc test

AC joint:

• Scarf test

Biceps tendon:

• Speed’s test

• Yergason’s test

Tendinopathy Investigations: Imaging

Not required

• Rule out other causes

XR/US/MRI

• Impingement syndrome

  • Narrow acromiohumeral distance

  • Osteoarthritis

Tendinopathy: Treatment

Conservative management

Refractory management

Tendinopathy Treatment: Conservative Management

Rest

Ice

Braces

Pain management

• Topical/oral NSAIDs

Physiotherapy: Strength training

Tendinopathy: Refractory Management

Indication: Pain ≥ 3 months

Corticosteroid injection

Platelet-rich plasma injection*

Topical nitroglycerin*

Extracorporeal shock wave therapy*

Surgery

• Debridement: Remove damaged tissue = Promote wound healing

• Tendon resection

Tendinopathy: Complications

Adhesive capsulitis (frozen shoulder syndrome)

Adhesive Capsulitis: Description

Inflammation + fibrosis of joint capsule = Shoulder joint contracture (movement restriction)

• Primary: Idiopathic

• Secondary: Previous shoulder injury + prolonged immobilization

Adhesive Capsulitis: Pathophysiology

Guarding + immobilization = Increase fibrosis + adhesions across glenohumeral joint = Function loss (movement restriction) + myofascial pain (localized knots in muscles)

Adhesive Capsulitis: Clinical Presentation

Pain

Stiffness

Restricted active + passive ROM

Adhesive Capsulitis: Treatment

Physiotherapy

NSAIDs*

Corticosteroid injections*

Surgery