Shoulder Pathology: Part 1 Motor Control and Mobility Deficits

what are the 6 principles of shoulder abduction?

• shoulder abducts due to scapulothoracic rhythm (120 GH abduction, 60 degrees scapular upward rotation)

• 60 degrees of scapular upward rotation is a result of SC joint elevation and AC joint upward rotation

• clavicle retracts at the SC joint

• upwardly rotating scapular posteriorly tilts and ER slightly

• clavicle posteriorly rotates around the own axis

• GH joint externally rotates

which conditions fall under shoulder pain with mobility deficits?

• adhesive capsulitis

• fractures

what is adhesive capsulitis?

aka frozen shoulder. Is classified as shoulder pain with mobility deficits. GH joint hypomobility due to thickened capsule and loss of axillary fold and decrease synovial fluid. prevalence for idiopathic is 2-5.3%, secondary is 4.3-38%

what are risk factors for primary adhesive capsulitis?

• DM I and II

• Hx (dupuytren’s contracture)

• age (40-65)

• thyroid

• gender (more common in females)

• Hx of adhesive capsulitis on 1 side

what are the causes and risk factors of adhesive capsulitis?

immobility, trauma, 2ndary to other NM issues causing capsuloligamentous fibrosis

what happens to the capsule in adhesive capsulitis?

capsule loses its pleating, the axillary and inferior pouch stiffens limiting the ability to elevate at the GHJ. the synovial fluid also gets thicker

which image demonstrates adhesive capsulitis?

right image

how long does the freezing stage of adhesive capsulitis last for?

10-36 weeks

what is stage 1/freezing of adhesive capsulitis characterized by?

• see the start of synovial inflammation

• increased pain, esp at end range

• primary complaint of ache then constant pain

• ROM limitations gradually progress (initially dx is usually impingement)

• minimal to no MS or postural changes beside pain/discomfort

• aggressive angiogenesis/joint changes

• loss of ROM in capsular patterns (ER > Abd > IR > Flex)

how long does stage 2 of adhesive capsulitis last?

4-12 weeks

what are the characteristics of stage 2/frozen stage?

• physiological process of inflammation is ending

• postural changes- looking for positions of comfort

• MS performance/motor control changes

• pain subsides to only at end of ROM

• stiffness persists w significant loss of AROM/PROM

how long does stage 3 of adhesive capsulitis occur?

12-42 weeks

describe the characteristics of stage 3/thawing of adhesive capsulitis?

• resolution begins

• ROM begins to spontaneously improve

• mean average of 30 weeks before symptoms commence resolving (from onset of symptoms)

  • comorbidities may delay timeframes

what is treatment like for adhesive capsulitis?

• most effective in late frozen to thawing phase

• joint mobilitizations are warranted

• ROM activity repetitively though the day based on SINS

• periscap strengthening as needed, mobility of the GHJ as needed, motor control for scapulo-thoracic and as GHJ resolves

what is the most common fracture in the shoulder region?

clavicle fracture because it is super stable medially via the coracoclavicular ligaments and since the force is designed to be transferred to the axial skeleton via the clavicle. the weakest portion is the middle and lateral 1/3 junction

what is the MOI of clavicle fractures?

• fall on lateral shoulder

• direct trauma

which demographic is clavicle fractures most common in?

children/adolescents

what are some associated injuries of clavicular fractures?

• pneumothorax

• rib fracture

what is the clinical presentation of a clavicle fracture?

pain, bruising, bone tenderness, visible step deformity maybe

what is the management of clavicle fractures like?

typically non surgical with figure 8 support for 6-8 weeks. begin AAROM and advance to AROM (clavicualr movements with association shoulder motion), MS performance interventions address musculature that attaches to the clavicle

describe proximal humeral fractures that are youth related

can occur due to trauma or excessive throwing. see epiphyseal stress fracture of shaft due to increase IR or ADD force, proximal fragments migrate upward due to pull of musculature

what is management like for proximal humeral fractures that are associated with youth?

rest initially, address the ROM, strength, motor control (coordination and proprioception/kinesthesia). progression will be guided by radiologic findings

describe proximal humeral fractures in the elderly

due to osteoporotic bone. see fractures most commonly in the surgical neck and more often in females. see increased risk with increased age. MOI often due to FOOSH or direct lateral trauma.

what nerve might a proximal humeral fracture at the surgical neck put into jeopardy?

The axillary nerve, which innervates the deltoid and teres minor muscles and is responsible for sensation over the lateral shoulder.

what is the clinical presentation of a proximal humeral fracture?

acute injury with pain, swelling, tenderness over the greater tubercle, crepitus, bruising possible to the forearm and hand. need to do an integrity assessment of the brachial artery, the median and musculocutaneous nerve, and assess the rotator cuff, deltoid, and pectoralis since they all attach on the proximal humerus

what is the management for non-displaced/minimally displaces proximal humeral fractures?

• treated non-surgically

• immobilization (slight distraction force) for 4 weeks bc need callous formation.

• decrease pain/apprehension then able to begin PT

  • goal is to avoid capsular contraction/should stiffness which can happen quickly but pts generally have a lot of pain

describe the surgical management for proximal humeral fractures

used for fractures with significant displacement (closed recution with/wo percutaneous pinning, ORIF). PT management following will be rigorous and prolonged, many pts can not tolerate

what are the outcomes like for surgical management of proximal humeral fractures?

outcomes vary, poor outcomes may be due to hardware being closer to the joint space and limiting motion. also might see poorer outcomes systemic disease like rheumatological conditions, also less than 10 degrees of LR leads to poorer outcomes

describe the typical PT mangement for surgically repaired proximal humeral fractures

• 0-1 weeks pain management and early mobility with PROM

• 1-6 weeks AAROM with joint mobilizations and strength

• 6-12 weeks advance all activities and improve proprioception

• 12-24 weeks return to activity, functional positions, plyometrics

describe scapular fractures

uncommon injuries, due to direct HIGH trauma, may present with rib injury, pulmonary trauma (pneumothorax), is classified according to location (body, neck, glenoid fossa, acromion, spine or coracoid

what is management for scapular fractures like?

typically non surgical, progressive pendulum'/PROM, + healing (callus formation), AAROM to AROM, progressive ms strengthening, especially scapular ms. average healing time is 6 weeks, remodeling up to 1 year

when is surgical repair needed for scapular fractures?

if the fracture occurs in the acromion/spine, coracoid, glenoid rim, intraglenoid

why might GHJ OA develop?

• repetitive microtrauma

• macrotrauma

• repetitive high load labor tasks

• BMI > 30 increases risk due to increased axial load and systemic inflammation

• strong correlation between rotator cuff health and decrease GHJ OA

which conditions fall under shoulder pain with movement coordination deficits?

• dislocations and subluxations

• labral tears

• instabilities that affect the capsuloligamentous structures

where can dislocations occur in the shoulder?

• SC joint tho is rare (3%)

• AC joint which is shoulder separation

• GH which is true dislocation

what is a 1st degree dislocation?

partial ligament tearing

what is a 2nd degree dislocation?

ligament is torn but the joint is intact

what is a 3rd degree dislocation?

ligament is torn, joint is detached

what direction does teh SC joint typically dislocate in?

anterior, MOI typically due to trauma (MVA or sports related)

what complications might a posterior SC joint dislocation lead to?

compression of vital organs (major blood vessles, esophagus, trachea, SOB, venous congestion, pneumothorax, dysphagai)

what is the clinical presentation of a SC joint dislocation?

• deformity, localized swelling, ecchymosis, pain

what is management like for SC joint dislocations?

• 1st degree protection for 3-4 days

• 2-3rd reduction, protection due to instability for 2-3 weeks, may require surgical repair

what is the MOI for AC dislocation?

FOOSh or elbow of shoulder trauma, direct trauma. (most frequently injured)

which grades of dislocation of the AC joint typically require surgery?

possible grade 3, 4-6 require surgery (see image for reference)

describe an anterior dislocation of the shoulder

most common type of dislocation, called a bankart lesion is the labrum is torn. often recurrent dislocation

describe the complications that are associated with glenohumeral dislocations

• nerve injury (axillary with inf or ant/inf, median with ant but uncommon, musculocutaneous with ant)

• RC, bicep, or labrum may be affected

• vascular changes (red flag)

what is the clinical presentation of GHJ dislocations?

palpation shows step off from acromion, humeral head is anterior (with subcoracoid dislocation), impaired ROM, possible muscular deficits

why might posterior GHJ dislocations occur (which are rare about 2% of cases)?

usually traumatic in nature, “cross body”, large force leads to a reverse hill sachs lesion (on medial side of the bone where get compressive fracture of the humeral head).

describe the clinical presentation of the posterior dislocation of the GHJ

decreased Extension/ER, horizontal adduction position

what is a SLAP lesion?

superior labrum anterior to posterior lesion- a tear of the superior labrum w or w/out proximal insertion of the long head of the biceps tendon

what are the gold standard diagnostic tests for SLAP tears?

• MRA for imaging (has enhanced visualization due to radioisotope)

• true gold standard is arthroscopic viewing

describe the 4 types of SLAP lesions

Type I: fraying of the superior labrum without biceps tendon involvement

Type II: tear of the superior labrum with biceps tendon detached

Type III: bucket handle tear of the superior labrum with intact biceps tendon

Type IV: bucket handle tear extending into the biceps tendon. part of the biceps anchor still intact

what is the MOI for labral tears?

• multifactorial (young may be due to bicipital groove anomonlies, repetitive overhead or trauma, older may be degenerative changes)

• FOOSH

• deceleration injuries (increase tensile forces as the biceps attmepts to decelerate elbow extension)

• acceleration injuries (late “cocking” phase of throwing, increased ER/ABD causing the tendon/labrum to be pulled off (peeled back) from the bone)

what does the image show?

labral tear- see the “oreo” sign inside the circled area- glenoid is dark, contrast is light, labrum is dark