painful shoulder

• mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space

• Most common cause of shoulder pain

• Pain with overhead reaching, a painful arc midrange, and positive impingement tests

• excessive or repetitive overhead activities

Impingement syndrome

• mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space

Impingement syndrome

• Most common cause of shoulder pain

Impingement syndrome

• Pain with overhead reaching, a painful arc midrange, and positive impingement tests

Impingement syndrome

• excessive or repetitive overhead activities

Impingement syndrome

What stage is this: Edema, hemorrhage (patient usually <25 years of age)

• Stage I.

What stage is this: Tendonitis/bursitis and fibrosis (patient usually 25 to 40 years of age)

• Stage II.

What stage is this: Bone spurs and tendon rupture (patient usually >40 years of age)

• Stage III.

are those that compromise the integrity of the musculotendinous structures:

• vascular changes in rotator cuff tendons

• tissue tension overload

• collagen disorientation and degeneration

INTRINSIC IMPINGEMENT: ROTATOR CUFF DISEASE

are those that compromise the integrity of the musculotendinous structures:

INTRINSIC IMPINGEMENT: ROTATOR CUFF DISEASE

• vascular changes in rotator cuff tendons

INTRINSIC IMPINGEMENT: ROTATOR CUFF DISEASE

• tissue tension overload

INTRINSIC IMPINGEMENT: ROTATOR CUFF DISEASE

is a result of mechanical  wear of the rotator cuff against the anteroinferior  one-third of the acromion in the suprahumeral space during elevation activities of the humerus.

Extrinsic impingement 

What are the 2 types of extrinsic impingement?

• Primary Extrinsic Impingement

• Secondary Extrinsic Impingement

What are the 2 factors of primary extrinsic impingement

anatomical factors

biomechanical factors

• result from  anatomical or biomechanical factors.

Primary Extrinsic Impingement 

• Structural variations in the acromion or humeral head

• Hypertrophic degenerative changes in the AC joint

• Other trophic changes in the coracoacromial arch or humeral head

• Anatomical factors: 

• Structural variations in the acromion or humeral head

• Anatomical factors: 

• Hypertrophic degenerative changes in the AC joint

• Anatomical factors: 

• Other trophic changes in the coracoacromial arch or humeral head

• Anatomical factors: 

• Altered orientation of the clavicle or scapula during movement

• Increased anterosuperior humeral head translation

• Biomechanical factors

• Altered orientation of the clavicle or scapula during movement

• Biomechanical factors

• Increased anterosuperior humeral head translation

• Biomechanical factors

TRUE OR FALSE: Neer suggested that the size and shape of the structures that make up the coracoacromial arch are related to rotator cuff impingement.

TRUE

TRUE OR FALSE: Neer suggested that only the size of the structures that make up the coracoacromial arch are related to rotator cuff impingement.

FALSE: size and shape

• Variations of the acromion were identified and classified  into three shapes which are?

• Type I: flat

• Type II: curved

• Type III: hooked

TRUE OR FALSE: Rotator cuff pathology is often associated with types II and III, but not type I acromial shape

TRUE

TRUE OR FALSE: Rotator cuff pathology is often associated with type I, but not type II and II acromial shape

FALSE: associated siya sa types II and III

Mechanical compression of the suprahumeral tissues 

due to:

• hypermobility or instability of the GH joint

• increased translation of the humeral head

Secondary Extrinsic Impingement

Secondary Extrinsic Impingement

Instability may be multidirectional or unidirectional and can occur with:

• compromised static restraints (GH ligaments) 

• dynamic rotator cuff insufficiency (force imbalances or fatigue

enumerate the secondary problems (this is under multidirectional instability)

• Impingement

• Sublaxation

• Dislocation

• Rotator cuff

• Tendinitis

• Bone spurs

• Tendon rupture

• Capsular restrictions and frozen shoulder

• Physiologically increased connective tissue  extensibility causing excessive joint mobility

• Increased extensibility allows larger than normal  humeral head translations in all directions

• Individuals involved in overhead activities develop laxity of the capsule from continually subjecting the joint to stretch forces

• A hypermobile GH joint may be supported by  strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization leads to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues

• Mechanical impingement of tissue in the suprahumeral space is a secondary effect of the increased humeral head translation.

Multidirectional instability

• Physiologically increased connective tissue  extensibility causing excessive joint mobility

Multidirectional instability

• Increased extensibility allows larger than normal  humeral head translations in all directions

Multidirectional instability

• Individuals involved in overhead activities develop laxity of the capsule from continually subjecting the joint to stretch forces

Multidirectional instability

• A hypermobile GH joint may be supported by  strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization leads to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues

Multidirectional instability

• Mechanical impingement of tissue in the suprahumeral space is a secondary effect of the increased humeral head translation.

Multidirectional instability

• Physiologically lax connective tissue

• Result of trauma and usually involves rotator cuff tears

Unidirectional instability with or without impingement

• Physiologically lax connective tissue

Unidirectional instability with or without impingement

• Result of trauma and usually involves rotator cuff tears

Unidirectional instability with or without impingement

• occurs with force against the arm when it is in an abducted and externally rotated position (MOI), and it frequently involves detachment of the anterior capsule and glenoid labrum (Bankart lesion

• Anterior instability

result of a forceful thrust against a forward-flexed humerus or fall on an outstretched arm (FOOSH)

• Posterior instability

• occurs in a position of  elevation, horizontal abduction, and maximum ER.

• Mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum.

• Associated with combination of posterior GH capsule tightness and scapula kinematic alterations

Internal Extrinsic Impingement

• occurs in a position of  elevation, horizontal abduction, and maximum ER.

Internal Extrinsic Impingement

• Mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum.

Internal Extrinsic Impingement

• Associated with combination of posterior GH capsule tightness and scapula kinematic alterations

Internal Extrinsic Impingement

What is the control produced during deceleration?

eccentric control

Which phase of baseball causes the most problem?

Arm cocking

Enumerate the conditions involved in tendonitis bursitis (stage II impingement syndrome)

supraspinatus tendonitis

infraspinatus tendonitis

bicipital tendonitis

subacromial tendonitis

• Difficult to differentiate from subdeltoid bursitis

• Painful arc with overhead reaching

• Pain with impingement tests and pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient’s hand is placed behind back

• Pain on palpation of the tendon

Supraspinatus tendonitis

• Difficult to differentiate from subdeltoid bursitis

Supraspinatus tendonitis

• Painful arc with overhead reaching

Supraspinatus tendonitis

• Pain with impingement tests and pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient’s hand is placed behind back

Supraspinatus tendonitis

• Painful arc with overhead, forward, or cross body  motions

• It may present as a deceleration (eccentric) injury  due to overload during repetitive or forceful throwing activities

• Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and externally rotates the humerus

Infraspinatus tendonitis

• Painful arc with overhead, forward, or cross body  motions

Infraspinatus tendonitis

• It may present as a deceleration (eccentric) injury  due to overload during repetitive or forceful throwing activities

Infraspinatus tendonitis

• Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and externally rotates the humerus

Infraspinatus tendonitis

• Lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament

• Pain occurs with Speed’s test and on the palpation of the bicipital groove

• swelling in the bony groove is restrictive and compounds and perpetuates the problem

Bicipital tendonitis

• When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendinitis

• Once the inflammation is under control, there are no symptoms with resistance

Subacromial / subdeltoid bursitis

• Lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament

Bicipital tendonitis

• Pain occurs with Speed’s test and on the palpation of the bicipital groove

Bicipital tendonitis

• swelling in the bony groove is restrictive and compounds and perpetuates the problem

Bicipital tendonitis

• When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendinitis

• Once the inflammation is under control, there are no symptoms with resistance

Subacromial / subdeltoid bursitis

• When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendinitis

Subacromial / subdeltoid bursitis

• Once the inflammation is under control, there are no symptoms with resistance

Subacromial / subdeltoid bursitis

Enumerate the muscles subjected to microtrauma (During racquet sports requiring a controlled backward, then a rapid forward swinging of the arm)

• Pectoralis minor

• Short head of biceps

• Coracobrachialis

Enumerate the muscles subjected to microtrauma (Functions to control forward motion of the scapula)

• Scapular retractors

Enumerate the muscles that may be injured during MVA (During MVA, the driver holds firmly to the steering wheel on impact)

• Long head of the triceps

• Scapular stabilizers

FILL IN THE BLANKS

Injury, overuse, or repetitive trauma can occur in any muscle being subjected to _____.

_____ occurs when the involved muscle is lengthened or when contracting against resistance.

Palpation the site of the lesion causes the familiar _____

stress

Pain

pain

FILL IN THE BLANKS

Injury, overuse, or repetitive trauma can occur in any muscle being subjected to _____.

stress

FILL IN THE BLANKS
_____ occurs when the involved muscle is lengthened or when contracting against resistance.

Pain

FILL IN THE BLANKS

Palpation the site of the lesion causes the familiar _____

pain

Insidious Onset (ATRAUMATIC ONSET)

Rotator cuff tears is equivalent to what stage of impingement syndrome?

Stage III impingement syndrome

Enumerate the common impairments related to painful shoulder syndromes Impingement syndrome 

Impaired Posture and Muscle Imbalances

Decreased Thoracic ROM

Rotator Cuff Overuse and Fatigue

Neuropathies like long thoracic nerve palsy

Tight posterior capsule

Enumerate the common  functional limitations/disabilities:

• When acute, pain may interfere with sleep

• Pain with overhead reaching, pushing, or pulling.

• Difficulty lifting loads.

• Inability to sustain repetitive shoulder activities

• Difficulty with dressing, particularly putting a shirt on over the head

Among the shoulder dislocations, this is the most common and its mechanism of injury is abduction and external rotation. it has the integrity of the following structures:

• Subscapularis

• GH ligament

• Long head of biceps

ANTERIOR DISLOCATION

Anterior dislocation has the integrity of which structures?

• Subscapularis

• GH ligament

• Long head of biceps