Clinical Orthopedics 222 Exam 3 Shoulder Impairments

Scapular Dyskinesia
-what is it

alteration in normal motion

SICK Scapula
-what is it

S-scapular malposition
I-inferior medial border prominence
C-coracoid pain and malposition
K-dyskinesis of scapular movement

The SICK Scapula
-signs and symptoms

Scapula appears lower; protracted
Inferior medial border prominent
Tight pec minor
Pain

The SICK Scapula
-signs and symptoms
o pain where

Anterior shoulder
Posterosuperior scapula
Superior shoulder
Proximal lateral arm

The SICK Scapula
-signs and symptoms
o pain in anterior shoulder

could be because of coracoid attachment

The SICK Scapula
-Why would a patient complain of anterior shoulder pain if the issue was their scapula??

it’s due to compensation

Treatment for SICK scapula

Stretching
Strengthening

Treatment for SICK scapula
-stretching
o which muscles

Pectoralis minor
Posteroinferior capsule

Treatment for SICK scapula
-strengthening
o how?

Open-chain and closed-chain exercises for scapular musculature and posterior rotator cuff

Treatment for SICK scapula
-what does this exercise work

the external rotators
as well U/L Trap

Tendonitis
-which stage is this

acute

Tendonitis
-what other stage could it be

Tendonosis (Chronic) (tendon degeneration)

Tendonitis
-what is it

Inflammation of the tendon

Tendonitis
-most common forms

(all in the greater tubercle)
Bicep’s Tendonitis
Supraspinatus Tendonitis
Rotator Cuff Tendonitis

Clinical Treatment for Tendonitis

Decrease pain and inflammation
Increase joint stability
STM
PROM
Cross Friction Message

Clinical Treatment for Tendonitis
Decrease pain and inflammation
-how so

Modalities as needed
Increase flexibility
Manual intervention

Clinical Treatment for Tendonitis
Increase joint stability
-how so

Initiate therapeutic exercise as tolerated
Joint stabilization activity (rotator cuff )

Surgical Interventions
Biceps Tenodesis

Cutting the bicep tendon then repositioning it to relieve pain or weakness

Surgical Interventions
Biceps Tenodesis
what can it involve
either what or what
Often preform with what

Can involve releasing the tendon from the labrum
Can involve relocating the tendon attachment
Arthroscopic(tiny incision) or Open(bigger opening)
Often performed with another surgical procedure of the shoulder

Subacromial Impingement
-what is it

Increased superior translation with shoulder elevation resulting in encroachment of the coracoacromial arch producing compression of the suprahumeral structures

Common Factors of impingement
Subacromial Impingement

Shape and Form of Acromion
Blood Flow to the rotator cuff
Dynamic Stabilizers
Condition of AC Joint
Positon of Arm during Activity (thumb pointed down)
Scapular Musculature Endurance
Capsular Tightness
Age

Subacromial Impingement
Surgical Interventions

Subacromial Decompression (S.A.D.)

Subacromial Impingement
Surgical Interventions
Subacromial Decompression (S.A.D.)

Arthroscopic (tiny incision surgery)
goal is to remove the cause of impingement to allow for more free movement

Subacromial Impingement
Surgical Interventions
Subacromial Decompression (S.A.D.)
what can it include

Removal of the bursa
Coracoacromial ligament resection
Anterior acromioplasty (changing the shape
Excision of outer clavicle(changing the clavicle)
Osteotomy of the glenoid or acromion

Surgical Intervention for Shoulder Pathology

Acromioplasty
Distal Clavicle resection

Surgical Intervention for Shoulder Pathology
Acromioplasty

Surgical removal of a piece of bone to allow for increased space within the joint space

Surgical Intervention for Shoulder Pathology
Acromioplasty
Distal Clavicle Resection

Removal of the end of the clavicle closest to the acromion to alleviate pain and loss of motion

Bursitis
-what is it

Inflammation of the Bursa

Bursitis
-what can happen with the synovial fluid

Synovial fluid can become infected or get irritated by movement

Bursitis
-symptoms

Localized tenderness
Warmth
Edema
Erythema(redness of the skin)
Loss of function

Treatment for Bursitis

PROM
STM

Dynamic stabilizers are…

Muscles

Static stabilizers are…

Joints, Ligaments

Posterior-Superior Glenoid Impingement (PSGI)

Common in throwing athletes
Compression of the supraspinatus and infraspinatus against the glenoid and labrum

Posterior-Superior Glenoid Impingement (PSGI)
Mechanism of Injury

Shoulder extension/abduction/external rotation

Posterior-Superior Glenoid Impingement (PSGI)
Treatment

STM, PROM (later on therex)

3 stages of impairment
Stage 1 (under 25 years of age)

Edema and hemorrhage
History of trauma or repetitive microtrauma
Pain with shoulder ABDuction over 90 degrees
Considered reversible at this stage
Typically responds to PT intervention

3 stages of impairment
Stage 2 (between 25-40 years of age )

Progressive detoriation
Fibrosis and tendonitis/tendonosis
Pain with daily activities and at night
Considered irreversible*
Supraspinatus and bicep tendon as well as subacromial bursa are fibrotic Pain with daily activities involving OH motions, at end of day

3 stages of impairment
Stage 3 (over 40 years of age)

Long history of shoulder pain
Significant muscle weakness
Osteophytes develop at acromion/ AC joint
Macrotrauma
-Tendon degeneration
-Rotator cuff tears
-Rotator cuff ruptures

3 stages of impairment
while the 3 stages of impairment may have range of age that it could happen in, what is more important

it’s mainly more so about the symptoms not the age

Rotator Cuff Repairs
2 categories

Partial thickness tear(grade 2)
Full Thickness tear(grade 3)

Rotator Cuff Repairs
Indications

Persistent pain that interferes with ADL’s
Unresponsive to conservative care
Active patients <50 yr old with an acute full thickness tear

Rotator Cuff Repairs
when treating a partial-thickness tear, what can we do

start with PROM, then eventually do strengthening

Rotator Cuff Repairs
When treating a Full thickness tear, what can we do

there’s not much we can do

Rotator Cuff Repairs
conservative care is how long

4-6 months

Open Rotator Cuff Repairs
-what is it

Vertical incision made over anterior shoulder
-Deltoid is divided allowing access to rotator cuff and subacromial space

Open Rotator Cuff Repairs
-how is it done

Anterior/inferior acromioplasty is performed
Humeral head is roughened
Holes are drilled for sutures
Sutures in place attaching tendon to bone

Arthroscopic Rotator Cuff Repairs
-what are some advantages to this

Smaller incisions
GH joint inspection
Treatment of intra-articular lesions
Avoidance of deltoid attachment
Less soft tissue dissection
Less pain

Post Surgical Care
-what happens

Period of immobilization
Gentle range of motion
-Glenohumeral
-scapulothoracic
Strengthening as per MD protocol
Manual intervention

Post Surgical Care
-general standards

Improvement in ROM noted for approx.
6 months
Return to strength in 12 months

Post Surgical Care
what is the limiting factor of healing for either procedure

the tendon to bone repair performed Immobilized for 3-8 weeks, potentially in an abduction sling

Glenohumeral Instability
-what is it

Generalized capsular laxity (umbrella diagnosis)
-“slipping” or “popping out” with activity or positions

Glenohumeral Instability
-what does this lead to

chronic subluxation/dislocation
-Anterior (Most Common)
o elbow flexion, abduction,ER
-Posterior
-Inferior

Glenohumeral Instability
-what is the primary complaint

pain
-possible instability complaints

Anterior Instability
-what is it

Most common direction of instability (FOOSH)
-Repetition towards anterior apprehension position
o External rotation and horizontal abduction

Anterior Instability
-what does the patient complain of

Pain with overhead movement
Impingement like symptoms
-Positions of abduction and external rotation

Other Directional Instability
posterior instability
-% of dislocations
-what position

FOOSH
>2% of dislocations
forward flexed, adducted

Other Directional Instability
posterior instability

Hyperabduction or inferior force (carrying heavy object)

Other Directional Instability
Multidirectional instability

GH instability in more than one direction
AMBRI

Other Directional Instability
Multidirectional instability
-who treats this

the PT

Other Directional Instability
Multidirectional instability
-what keeps it in place

the acromion process of the scapula

Other Directional Instability
Multidirectional instability
what does AMBRI stand for

atraumatic
multidirectional
bilateral
rehabilitation (first attempt)
inferior capsule tightening

Other Directional Instability
Multidirectional instability
treatment?

Mainly, physical therapy is first
Surgery is a last resort because the success rate is low

Shoulder Dislocations
-what is it
-what gender gets it more

Shoulder is the most commonly dislocated joint in the body
Men more often than women*

Shoulder Dislocations
-Anterior

(more common, thought females are more hypermobile)
shoulder ABDuction, extension, and external rotation

Shoulder Dislocations
-posterior

shoulder ABDuction, flexion, and internal rotation

TUBS
-what direction
-symptoms?
-what treatment is first

-anterior since is most common
-(bankart)associated symptoms
-surgery is the first approach

AMBRI
-what is the difference compared to TUBS

conservative first approach; then capsulorrhaphy when they tighten the capsule

GH Joint Instability Treatment
Conservative treatment ?

Dynamic strengthening (rotator cuff, serratus anterior, trapezius, deltoid )
Stability activities

GH Joint Instability Treatment
Surgical intervention?

last resort! (The success rates are low and typically will experience reloosening of capsule and more dislocations, subluxations )
“Capsulorrhaphy”
Tightens the inferior capsule
Tightens the rotator interval

Labral tears
SLAP Lesions(Superior Labrum Anterior to Posterior)
-causes?

Repetitive overhead movements
FOOSH injury (fall out on stretched handO
Sudden deceleration/traction forces
MVA (car accident)
Chronic ant/post instability

Labral tears
SLAP Lesions
type 1

Fraying and degeneration of superior labrum
Can not horizontally ABD or ER with forearm pronation without pain

Labral tears
SLAP Lesions
type 2

Pathologic detachment of the labrum and biceps tendon anchor
Loss of stabilizing effect of labrum and biceps

Labral tears
SLAP Lesions
type 3

Vertical tear of the labrum
Remaining portions of labrum and biceps are intact

Labral tears
SLAP Lesions
type 4

Extension of tear into the biceps tendon
Portion of labrum and biceps tendon displaced into GH joint

what is the range of a SLAP Lesion tear

11-1

what is the range of a Bankart lesion

2-6 o clock

Bankart Lesion
-what is it

Avulsion of the anterior inferior labrum from the glenoid rim

Bankart Lesion
-requires what

Requires surgical stabilization
“TUBS”
Traumatic
Unidirectional instability
Bankart lesion requiring
Surgery

Hills-Sachs Lesion
-what is it

Compression fracture on the posterior humeral head at the site where the humeral head impacted the inferior glenoid rim

Hills-Sachs Lesion
-what 2 parts are it

part labrum tear
part fracture

Hills-Sachs Lesion
-Treatment?

can’t do much, just let it heal on its own

Labral Tears -treatment
-what is treated first

Conservative treatment is attempted first

Labral Tears -treatment
after conservative treatment is attempted first
-what comes next

Avoidance of provocative position
Gentle ROM/ submaximal isometric exercises
Scapular stability exercises
Closed chain exercises (used to give feedback
Improve scapulohumeral rhythm
Open chain activities (used for moving more)

Surgical Interventions for Labral Tears
-who is this mainly for

For persons who remain symptomatic following conservative therapy
For persons whose instability is so gross that conservative therapy is not appropriate

Surgical Interventions for Labral Tears
-what are the types

Bankart Repair
Capsulorrhaphy
SLAP Repair

Adhesive Capsulitis (Frozen Shoulder)
-what demographic is this most common in

Most common in women between 40 and 60 years old

Adhesive Capsulitis (Frozen Shoulder)
-what is it

“stuck” shoulder , inflammation of capsule

Adhesive Capsulitis (Frozen Shoulder)
-often what

Insidious Onset
-sudden/came out of nowhere

Adhesive Capsulitis (Frozen Shoulder)
-what could possible cause this

trauma
-immobilization
Diabetes
Thyroid disease (hypo and hyper)

Adhesive Capsulitis (Frozen Shoulder)
-symptoms include?

Decreased Shoulder ROM
Pain
Capsular Inflammation
Fibrous Synovial adhesions
Reduction of joint cavity

Capsular pattern of the shoulder
what is most limited?

External rotation then Abduction then Internal rotation
Sometimes flexion is involved with Abduction

what is the most difficult Rehab

Shoulder rehab that is post op or no op is the most difficult

Adhesive Capsulitis (Frozen Shoulder)
-primary?

Progressive and painful loss of ROM

Adhesive Capsulitis (Frozen Shoulder)
-Secondary?

Trauma or immobilization

How to treat Adhesive capsulitis (Frozen Shoulder)

Current literature is inconclusive as to the best way to treat it

Stages of Progression of Adhesive Capsulitis (Shoulder Frozen )
1.Freezing

Intense pain at rest
Capsular pattern loss of motion
Painful inflammation
10-36 weeks

Stages of Progression of Adhesive Capsulitis (Shoulder Frozen )
2.Frozen

Pain with movement
Loss of ROM in ALL planes
weakness
4-12 months

Stages of Progression of Adhesive Capsulitis (Shoulder Frozen )
3.Thawing

Slow, steady recovery of ROM
-doing PROM but it does not go past available ROM
-Doing a lot of stretching and mobility work

Adhesive Capsulitis (Shoulder Frozen )
-what does this impact

everyday function of the patient that has this