Shoulder Pathologies

Rotator Cuff pain/Subacromial Pain Etiological factors

Excessive and maladaptive load on tissues

Genetics, lifestyle (smoking, alcohol), comorbidities, pathoanatomical factors

Rotator Cuff pain/Subacromial Pain pathophysiology

Inflammation causing pain

Chronic strain under coracoacromial ligament

Muscle weakness (rotator cuff)

Rotator Cuff pain/Subacromial Pain Common SSx

Pain w/ muscle weakness (MMT <3)

Pain/impairment during shoulder elevation and ER

Painful arc 90-198 deg

Night pain common

Rotator Cuff pain/Subacromial Pain Test Cluster

Neer’s test

Hawkins Kennedy

Painful arc

Empty can

TOP greater tuberosity/subacromial space

Scapular dyskinesis

Rotator Cuff pain/Subacromial Pain MOI

Excessive and maladaptive load on shoulder tissues

Repetitive strain injury, nerve dysfunction, or degeneration of rotator cuff

Rotator Cuff pain/Subacromial Pain Anatomy

Rotator cuff muscles/tendons

Subacromial bursa

Coracoacromial ligament

Acromion

Rotator Cuff pain/Subacromial Pain Screening

Referred pain

Exclude Frozen shoulder and shoulder instability

Cervical radiculopathy (DDx)

Rotator Cuff pain/Subacromial Pain Imaging

US - tendons

MRI - adhesive capsulitis

Rotator Cuff Tear Etiology

Combination of injury and weakening of tendon due to wear and tear

Extent depends on tendon quality

Increasing age (25% in >50 y.o., 20% > 20 y.o.)

Smoking, Poor posture, occupations requiring significant overhead work

Rotator Cuff Tear Pathophysiology

Symptomatic or asymptomatic

Full thickness tears do not heal, but can stabilize

Degenerative or traumatic

Large tears - proximal humerus may migrate superiorly

Long head biceps demonstrates hyperactivity

Rotator Cuff Tear Common SSx

Pain

Weakness, pain, loss of ability to use shoulder

Difficulty sleeping on affected shoulder

Limited AROM

Catching/grinding fleeing

Muscle atrophy

Painful arc during shoulder elevation

Rotator Cuff Tear Test Cluster

Painful arc test

Drop arm test

ER resistance test

Rotator Cuff Tear MOI

Elevated arm is forced downward

Sudden jerky lift

Macro or micro-trauma

Rotator Cuff Tear Anatomy

Rotator Cuff

Humeral head

Subacromial bursa

Rotator Cuff Tear Screening

Distinguish arthritis, bursitis, frozen shoulder, neck radiculopathy

Rotator Cuff Tear Imaging

US, MRI

Adhesive Capsulitis (Frozen Shoulder) Etiology

Idiopathic

Secondary to surgical procedures

Genetic predisposition

Diabetes, thyroid disease, CAD

Adhesive Capsulitis (Frozen Shoulder) Pathophysiology

Intense shoulder pain and progressive limitation of AROM and PROM

3 consecutive stages: Pain/freezing, Stiffness/Frozen, Recovery/Thawing

Inflammation followed by fibrosis, thickening and shortening of joint capsule

Coracohumeral ligament becomes stiffer

Adhesive Capsulitis (Frozen Shoulder) Common SSx

Spontaneous onset shoulder pain followed by progressive loss of AROM and PROM

Severe pain, inability to sleep at night

Dull and poorly localized pain

Joint stiffness worse in ER, abduction, flexion

Adhesive Capsulitis (Frozen shoulder) Test Cluster

AROM + PROM significant reduction (ER, ABd, IR)

End feel - firm capsular

Pain pattern - Worse at night and end range

Special tests - usually negative

Imaging - normal x-ray

Adhesive Capsulitis (Frozen Shoulder) MOI

Spontaneous inflammation and subsequent fibrosis

Secondary to surgical procedures or local trauma

Adhesive Capsulitis (Frozen Shoulder) Anatomy

Glenhoumeral joint capsule

Pericapsular soft tissue

Coracohumeral ligament

Subcoracoid fat triangle

Axillary pouch

Surrounding Musculature

Adhesive Capsulitis (Frozen Shoulder) Screening

Typically Screen others against this

calcific tendinitis, arthropathy, bursitis

Adhesive Capsulitis (Frozen Shoulder) Imaging

MRI

OA of Shoulder/GHOA Etiology

Advancing Age, Women>Men

Secondary OA - due to predisposing conditions (chronic dislocations, trauma, AVN)

Chondrolysis, arthropathies

OA of Shoulder/GHOA Pathophysiology

Destruction of articular surface of humeral head

Rotator cuff arthropathy

Abnormal gelnoid, dysplasia, hypoplasia, humeral head abnormalities

OA of Shoulder/GHOA Common SSx

Pain, felt deep in joint

Progressive, sustained, activity-related

Worse at night/rest

Limited active and passive GH ROM

OA of Shoulder/GHOA MOI

Destruction of articular surface of humeral head

Chronic dislocations, instability, trauma, AVN, inflammation

OA of Shoulder/GHOA Anatomy

Articular surface of humeral head and glenoid

Synovium and subchondral bone

Rotator cuff (if arthropathy present)

OA of Shoulder/GHOA Screening

Adhesive Capsulitis (Frozen Shoulder), RA, arthropathies, instability, Rotator cuff tendinopathy, Calcific tendinitis, Cervical Radiculopathy

OA of Shoulder/GHOA Medical imaging

Plain radiographs - primary diagnostic tool

Glenohumeral instability Etiology

Repetitive Microtrauma

Congenital, developmental, psychological

Congenital absence of long head of biceps

Glenohumeral instability Pathophysiology

Shoulder joint is inherently unstable

Disruption of one or more of the static or dynamic stabilizers

Multidirectional instability (MDI) microtrauma to capsule and ligaments due to repetitive use and stretching

Abnormal scapular kinematics and muscle activation patterns

Glenohumeral instability Common SSx

Younger patient <25 y.o.

Subtle injury, laxity

Frequent subluxations

Subjective Shoulder insecurity/distrust

Glenohumeral instability MOI

Direct trauma - dislocation

Repetitive microtrauma

Compression type injuries/ Traction type injuries

Peel back mechanism in overhead athletes

Glenohumeral instability Anatomy

Static stabilizers - ligaments, capsule, bone stock

Dynamic Stabilizers - Rotator cuff muscles, long head of biceps, deltoid, periscapular

Humeral head and glenoid fossa

Labrum

Glenohumeral instability Screening

Rule out referred pain/serious pathology

Cervical and neurological pathologies

Ehlers-Danlos syndrome

Glenohumeral instability Imaging

Plain radiographs

MRI - soft tissue

US - subacromial space

Acromioclavicular Joint Pain (ACJ Pain) Etiology

Common Shoulder injuries -40% of all, 10% of all injuries in collision sports

Sporting events, car accidents, falls from bicycles

Acromioclavicular Joint Pain (ACJ Pain) Pathophysiology

Rockwood classification system:

• 1: AC ligament sprain, CC ligament intact, no radiographic abnormalities

• 2: AC ligament torn, CC ligament sprain, clavicle elevated (<25% increase in CC space)

• 3: AC and CC ligaments torn, clavcile above acromion border (25-100% increase in CC space)

• 4: Posterior displacement of distal clavicle into trapezius

• 5: Superior displacement of distal clavcile by > 100% compared to contralateral side

• 6: Inferolateral displacement, behind coracobrachialis/biceps tendon (rare)

Acromioclavicular Joint Pain (ACJ Pain) Common SSx

Anterosuperior shoulder pain

Worse w/ movement/trying to sleep on affected shoulder

Swelling, bruising, deformity of AC joint

TOP AC joint

Acromioclavicular Joint Pain (ACJ Pain) MOI

Direct trauma to lateral aspect of shoulder or acromion process w/ arm in adduction

FOOSH - ACJ separation

Acromioclavicular Joint Pain (ACJ Pain) Anatomy

AC joint

AC ligament

CC ligament

CA ligament

Clavicle

Acromioclavicular Joint Pain (ACJ Pain) Screening

Evaluate entire clavicle - fracture

Neurovascular exam

Impingment, RC injury, superior labral tears, dislocation

Acromioclavicular Joint Pain (ACJ Pain) Imaging

X-rays

Weighted stress views

Long Head of Biceps Pain (LHBT Pain) Etiology

Vague, inconsistent complaints of exertional anterior shoulder pain

Repetitive overhead use

Concomitant injuries (labral tears, bursitis, arthritis)

Shallow bicipital groove

Long Head of Biceps Pain (LHBT Pain) Pathophysiology

Degenerative changes in tendon

Secondary tendinopathy - degeneration accompanies subacromial impingement

LHBT instability

Increased biceps activity with rotator cuff deficiency

Long Head of Biceps Pain (LHBT Pain) Common SSx

Pain localized to anterior shoulder, over the bicipital groove

Reports sensation instability, popping, and grinding

Worse with heavy lifting, pushing, and overhead motions (non-specific)

Long Head of Biceps Pain (LHBT Pain) MOI

Hx of repetitive overhead use

Peel-back mechanism - overhead athletes

Long Head of Biceps Pain (LHBT Pain) Anatomy

LHBT

Bicipital groove

biceps sling (CH ligament, superior GH ligament, transverse humeral ligament)

Biceps tendon sheath

Subscapularis tendon

Long Head of Biceps Pain (LHBT Pain) Screening

Consider Concomitant Pathologies - Rotator cuff disease, SLAP tears, instability, bursitis, arthritis

Long Head of Biceps Pain (LHBT Pain) Imaging

US - high specificity for dislocations/subluxations

MRI - can predict presence

Labral Pathology (Slap lesions and tears) Etiology

Young laborers, overhead athletes, middle-aged manual laborers

Acute traumatic: Compression, traction, Combined

Attritional SLAP injuries common in overhead athletes

Sudden jerking force with onset of pain

Labral Pathology (Slap lesions and tears) Pathophysiology

SLAP Lesions involve glenoid labrum fibrocartilage

Types:

• 1: Superior labral fraying with intact biceps anchor

• 2: Detachment of superior labrum/biceps anchor from superior glenoid

• 3: Bucket-handle tear of superior labrum with intact biceps anchor

• 4: Bucket-handle tear of superior labrum with extensions into biceps tendon

Labral Pathology (Slap lesions and tears) Common SSx

Acute onset deep shoulder pain

Mechanical symptoms: popping, locking, catching

Exacerbated with activity, improved with rest

Unable to sleep on affected shoulder, reach behind their back, perform overhead press

Labral Pathology (Slap lesions and tears) MOI

Acute - traumatic, compression, traction

Repetitive overhead activities - peel-back mechanism

Labral Pathology (Slap lesions and tears) Anatomy

Superior glenoid labrum

Glenohumeral joint capsule

Biceps tendon anchor

Middle and inferior glenohumeral ligament (MGHL and IGHL)

Labral Pathology (Slap lesions and tears) Screening

Co-existing cervical radiculopathy

Impingement, rotator cuff syndrome, LHBT tendinopathy, AC arthritis

Labral Pathology (Slap lesions and tears) Imaging

X-ray, MRI, Arthroscopy - gold standard for SLAP lesion identification