MSK 3: Shoulder Pathology Basics

NEER stages of RTC pathology

Stage 1: acute tendinitis, <25 y/o

Stage 2: tendinosis and partial thickness tears, 26-40 y/o

Stage 3: full thickness tendon tear, >40 y/o

Subacromial vs. internal impingement

-subacromial: bursal-sided RTC compression on acromion/coracoacromial arch, at any age; occurs at lower ranges of GH elevation <70-80°

-internal: articular-sided compression at posterior/superior glenoid, any age (most common); shoulder pain at >140° elevation and >90° horiz. ABD

Snyder classification of SLAP tears

Type I: degenerative, not considered source of sx (normal with age)

Type II: labral tear with biceps anchor that is unstable

Type III: bucket handle labrum tear biceps intact

Type IV: bucket handle tear extends to include the biceps

CPG categories

1. Muscle performance deficit/subacromial pain

2. Mobility deficit/adhesive capsulitis

3. Motor coordination/instability

Muscle performance deficit/subacromial pain dx

• RC tendon tear*

• Subacromial impingement/pain syndrome

• RC related pain

• Bursitis

• Biceps tendinitis

Mobility deficit/adhesive capsulitis

• primary capsulitis

• GH OA

• Post traumatic/surgical arthrofibrosis

Motor coordination/instability

Ligament

• GH dislocation

• GH ant/inf, post instability

• Multidirectional instability

• AC joint sprain/separation

Labrum

• SLAP tear

Tendon

• internal impingement

SAPS: sx behavior

-pain in deltoid (sharp/shooting) and distally (dull/aching), above elbow

-aggravating: using arm at/above shoulder height, overuse, sleeping on involved shoulder, reaching behind back

-alleviating: rest, supporting arm

-nature: dull/achy or sharp/catching with ABD and overhead activity

Rule in SAPS with:

-subacromial impingement cluster: Neer, Hawkins, painful arc, Jobe, resisted ER

What are your differential dx's with SAPS?

-stiff GH pathologies (OA, AC): rule out with normal passive mobility

-instability: rule out with negative instability tests

T/f someone with secondary impingement will have + laxity tests with apprehension that is relieved with relocation

True

SAPS: contributing factors

-posterior inferior GH ligament / capsule tightness

-RTC muscle performance

-scapular muscle performance

-thoracic spine mobility

-scapular mobility (pec length, T-spine)

RTC full-thickness (stage III) tear: risk factors

-trauma

-smoking

-genetics

RTC full-thickness (stage III) tear: sx behavior

-same location as SAPS: deltoid, above elbow

-on/off sx for years

-traumatic onset ages<40 or atraumatic reaching overhead ages>40

-pain, weakness, inability to perform UE ADLs

-aggravated by ABD/elevation, reaching behind back, sleeping on involved side

Rule in RTC full-thickness (stage III) tear with:

-mild to substantial RTC weakness (size-dependent)

-AROM loss significantly > PROM

-positive lag signs / special tests when large-massive

-positive imaging findings

RTC full-thickness (stage III) tear: contributing factors

Same as SAPS with...

-RTC weakness

-poor scapulothoracic mobility attributed to T-spine/pec minor/lats length

-GH joint / posterior shoulder hypomobility

Bankart lesion

Avulsion of anterior-inferior labrum and capsule from glenoid rim, usually with anterior dislocation

Hill-Sachs lesion

-compression fx of posterior humeral head d/t impact on anterior glenoid

-usually with anterior dislocation

Anterior GH dislocation: potential red flags

-glenoid fracture (bony Bankart)

-GT fracture (up to 30% ages>40)

-RTC tear (traumatic dislocation in older adults)

T/f if you suspect an anterior GH dislocation, P should always get imaging before beginning PT

True

Anterior GH dislocation: sx behavior

-feeling of "shoulder is out", reports dislocation

-c/o extreme pain

Anterior GH dislocation: objective findings

-pain in deltoid region

-sulcus sign

-"flattened" deltoid

-following reduction: pain, RTC weakness, contributing impairments

Once anterior or posterior GH dislocation is reduced, what do you also want to evaluate for?

-axillary nerve injury

-RTC tear

Rule in Anterior GH dislocation with:

-subjective report and x-ray

Posterior GH dislocation: mechanism

-trauma in flex/ADD position

-risk factors: trauma, seizures

Posterior GH dislocation: objective

-pain in deltoid and posterior shoulder

-less obvious deformity

Posterior GH dislocation: mgmt

-immobilization 7-10 days, if at all

-then focus on gradual increase in ROM and strengthening dynamic stabilizers (RTC, kinetic chain)

Atraumatic instability: mechanism

-GH ligamentous laxity or micro-traumatic stretching of capsular structures results in pain/instability/giving way/subluxation in positions that stress the involved structures

-once hypermobility and instability is established, can result in RTC sx from overuse (secondary/internal impingement)

T/f once hypermobility and instability is established, it can result in RTC sx from overuse (secondary/internal impingement)

True

Which position strains anterior capsule and is possibly associated with shortened posterior capsule/shoulder structures?

ABD+ER: repetitive strain in this position can cause lengthened anterior capsule and shortened posterior capsule

T/f atraumatic instability is typically younger patients associated with repetitive overuse

True

T/f Atraumatic instability sx behavior depends on direction

True

Unidirectional anterior instability: sx behavior

-pain and apprehension with combined positions of ER+ABD (combing hair, putting arm through jacket, throwing)

-internal impingement associated: posterior pain

Unidirectional posterior instability: sx behavior

-pain and apprehension with activities producing a posterior force through the shoulder (pushing door open, push ups)

-combined positions of IR, horiz. ADD, and flexion

Which positions cause apprehension with posterior instability?

-posterior force through humerus

-combined positions of IR, horiz. ADD, flexion

Which positions cause apprehension with anterior instability?

Combined positions of ABD+ER

Multidirectional instability: sx behavior

-“double jointed”

-may describe multiple episodes of subluxation with low irritability afterwards

-pain or instability at end-ROM; could be in single plane (most stressful/repetitive) or multiple planes

-hx of overhead sports

-suspect hypermobility syndromes

-+Beighton Scale

Unidirectional anterior instability: objective and rule in

-PA hypermobile (guarding/pain), AP (hypomobile), inferior (hypermobile/normal)

-ER increases pain/sx, particularly in ABD

-decreased strength and/or pain with shoulder strength testing

-(+) signs of secondary impingement (Neer/Hawkins)

-rule in: + anterior apprehension test, relocation test, surprise, sulcus sign, hyperABDuction (Gagney)

Unidirectional posterior instability: objective and rule in

-AP (hypermobile), inferior (typically hypermobile)

-IR increases pain/sx, particularly in flexion

-+ sulcus sign

-rule in: posterior apprehension test and hyperabduction test (Gagney)

Rule in multidirectional instability with:

-anterior and posterior apprehension tests

-hyperABD (Gagney)

Atraumatic instability: contributing factors

-hypermobile posterior/inferior GH

-RTC, scapulothoracic, core weakness

-same as SAPS with factors that would contribute to excessive anterior translation

T/f PT is the preferred treatment for atraumatic instability

True

SLAP tear: MOI

-usually occurs with atraumatic instability

-excessive humeral head translation, traction injury, or superior shear force from fall with arm flexed and humerus forced superiorly

-peel back from biceps during cocking phase of throwing

SLAP tear: sx behavior

-consistent with instability and impingement (pain in deltoid, aggravated by overhead use, reaching behind back, sleeping on involved shoulder, pain/apprehension) with potential clicking/popping

SLAP tear: objective and rule in

-consistent with anterior instability and impingement: ER increases pain/sx, decreased strength/pain with strength testing, PA and inferior glide hypermobile, positive impingement cluster

-rule in: special tests are not good, best evidence is cluster of special tests and hx of clicking/popping

Tests to rule in slap type II:

-anterior slide

-compression rotation

-yergason's

SLAP tear: contributing factors

-GIRD

-RTC weakness

-kinetic chain strength and endurance

T/f For SLAP tear rehab is 1st line, should trial at least 6 months addressing patient specific impairments such as GIRD and horiz. ADD ROM and scapular/RTC strength

True

Adhesive capsulitis: 4 stages

-stage I: mild sx <3 mo., achy at rest and sharp pain at end-ranges (ER&ABD most affected), no ROM loss

-stage II: "freezing" 3-9 mo., onset of ROM loss in all planes, all ranges very painful with capsular limitation, empty/guarding end feels, synovitis/angiogenesis

-stage III: "frozen" 9-14 mo., severe PROM limitations ER>ABD>IR but pain diminishes

-stage IV: "thawing" 14-24 mo., pain resolves, primary complaint is loss of ROM that gradually recovers

T/f adhesive capsulitis is characterized by painful loss of AROM=PROM ER>ABD>IR, so patient is unable to reach overhead, behind back, or into pocket

True

For stage III adhesive capsulitis, what grade mobilizations should be used?

Grades III and IV

T/f diabetes is a risk factor for Adhesive capsulitis

True

Adhesive capsulitis: sx behavior

-gradual onset and progressive worsening of pain (diffuse), and then stiffness

-diffuse pain and stiffness limit sleeping, grooming, dressing, and reaching activities

-stage I-II nature: significant constant burning/ache with sharp pain at end-ranges

-stage III-IV nature: chief complaint is mobility deficit

Primary vs. secondary Adhesive capsulitis

-primary: idiopathic

-secondary: d/t trauma, surgery, immobilization

Adhesive capsulitis: objective exam to rule in

-GH AROM and PROM loss in ER, ABD, IR (2+ planes, >30%)

-accessory motion hypomobile or guarding depending on stage

-strength in available ROM usually NOT impaired, unless stage I d/t pain

With adhesive capsulitis, is strength usually impaired?

-strength usually NOT impaired in available ROM, unless stage I d/t pain

Adhesive capsulitis: differential dx

-GH OA: rule out with x-ray

-SAPS (stage I)

Compare and contrast stage I adhesive capsulitis vs. SAPS

-different courses of progression

-AC pain is achy at rest; SAPS rest is alleviating

-AC pain is more diffuse; SAPS is deltoid to elbow

-both can be sharp/catching with overhead movement (SAPS) and end-ranges (AC)

-both ABD is aggravating

T/f x-ray should be used to rule out GH OA when considering Adhesive capsulitis

True

Shoulder pathologies affecting older people:

-GH OA

-AC OA

-adhesive capsulitis

-anterior GH dislocation (falls)

-atraumatic RTC tear

-could be SLAP tear

Shoulder pathologies affecting younger people:

-instability

GH OA: subjective sx

-usually ages>60 unless serious trauma

-significant trouble sleeping

-onset of stiffness/loss of ROM usually precedes pain

T/f with GH OA stiffness/ROM loss usually precedes pain

True

GH OA: differential dx

-stage II-III primary adhesive capsulitis

GH OA: objective / rule in

-loss of GH ROM in all planes, hypomobility

-crepitus

-strength loss is mild but limited by pain

-confirm dx with radiography or MRI if radiographs unclear

T/f recommended intervention for GH OA is surgery, lack of evidence for PT/NSAIDs/injections

True

AC joint sprain: risk factors

-athletics d/t trauma/contact with superior to inferior force on distal shoulder

-i.e. tackling, checks

AC joint sprain: MOI

-superior to inferior force on distal shoulder

AC joint sprain: grading

-grade I: slight displacement, intact or partially torn AC ligament

-grade II: partial dislocation, AC ligament torn but coracoclavicular ligament intact

-grade III: complete separation; AC ligament, coracoclavicular ligament, and capsule torn; step off deformity

Step off deformity

-seen with grade III AC joint sprain

AC joint sprain: subjective sx behavior

-pain on superior shoulder

-aggravated by sleeping on involved side, horiz. ADD, and end-range

Which pathologies are aggravated by sleeping on invovled side?

-SAPS

-RTC tear

-AC joint sprain

-AC joint OA

Which pathologies make it hard to sleep d/t pain?

-GH OA

-adhesive capsulitis

T/f AC joint sprain and OA are aggravated by sleeping on involved side and horiz. ADD, and AC joint sprains are also aggravated by end-range

True

AC joint sprain: objective

-step off deformity (grade III)

-tender to palpation along superior shoulder / AC jt

-limitation in horiz. ADD and full elevation PROM/AROM with pain reproduced

-supports elbow close to side

-popping with motion

-AC jt accessory mobility increased/painful

T/f with AC joint sprains, the patient will have limited horiz. ADD and full elevation AROM/PROM with pain

True

AC joint OA: risk factors

-older age

-heavy weight lifter/labor

T/f AC jt OA typically presents similar to a grade I sprain but in older adults and hypomobile

True

AC joint OA: sx behavior

-traumatic or insidious

-pain on superior shoulder

-aggravating: sleeping on involved side, horiz. ADD, daily activities

AC joint OA: objective to rule in

-notable hypertrophy, osteophytes

-tenderness with palpation of superior shoulder/AC joint

-limited horiz. ADD but full elevation AROM/PROM with pain reproduced

-AC accessory hypomobile and painful

-imaging to differentiate from other AC jt disorders

AC joint OA: management

-prefer conservative tx with injection, PT, activity modification

-restore mobility (anterior, posterior, caudal) and address weakness if present

-surgery if persistent pain despite PT