types of injury: strain vs. sprain
strain: contractile tissue only (muscle/ tendon) sprain: noncontractile- joints, ligaments and capsules; usually associated with trauma. The degree to which the noncontractile structure is sprained is what determines the instability of the joint
allows mobility but sacrifices stability- shoulder pain 3rd most common complaint.
common problems with the shoulder
arthritis in any of the contributing joints (SC, AC, ST, GH, SubA), tendinitis, rotator cuff tear, instability, bursitis, calcific tendonitis, strain
shoulder pain can be difficult to dx d/t ?
both intrinsic and referred pain patterns from neck, heart, organs or arm
Flexion and extension Abduction and adduction External and internal rotation Horizontal abduction and adduction
age and common shoulder problems
youth- strain of muscle or traumatic- fractures and dislocations. Overuse in play/ sport. There is usually a precipitating event.
middle age- tendonitis/bursitis postural or overuse
elderly- NOT TRAUMATIC rotator cuff tear and adhesive capsulitis. Arthritis.
sequence of exam
observe- color, asymmetry, deformity, swelling, general distress, atrophy, rupture
palpation/ inspection- temp., sensitive areas. AC joint, SC joint, biceps tendon and c spine are usually reliable. At the acromiom border- think RC and bursae.
ROM- passive and active
MMT and special tests- designed to stress suspected structures
term currently used for the conditions of subacromial bursitis, rotator cuff tendinitis, supraspinatus tendinitis, and painful arc syndrome.
the tendons of the SITS group: supraspinatus, infraspinatus, teres minor, subscapularis
RC tendonitis and impingement symptoms
Pain with certain motions- especially overhead, rotatory, and abduction (driving, doing hair)
Pain at night- trouble sleeping- “noc ischemia” phenomenon- teach them elevation with pillow
Can have traumatic or overuse history. Can be insidious.
Deltoid area pain is common area of referred pain
Tests for RC Tendinits/ Impingement
Painful arc – between 65-120 is painful.
+ Apley Scratch- opp shoulder blade, opp inf angle scap.- doing this reproduces the pain
+ Neer- passive flexion of the shoulder with the scap stabilized and FA in pronation
+ Hawkins- passively flex the shoulder to 90, bend elbow, internally rotate
Empty can- hold “soda can” out, then turn it over to dump out the soda.
This first step of the Apley Grind is also called the cross arm test. It compresses the AC joint and pain in this area during the maneuver is positive for AC arthritis.
passive flxn of the shoulder with the scap stabilized and FA in pronation
passively flex the shoulder to 90, bend elbow, internally rotate
Age or Trauma; history of impingement
Drop Arm Test- passively lift the arm, ask to hold
Belly press- test for subscapularis tear
Lift off test behind the back test- test for subscap tear
belly press sign
can’t press into their own belly. If large abdomen, try Lift Off test.
Supraspinatus and Infraspinatus Atrophy
Usually due to overuse
Can be sudden
Pain at tip of acromion into deltoid area
Difficult to discriminate between bursitis and tendinitis
Painful overhead motion
Painful to sleep on it
Pain with use
Throwing athletes- arm swing athletes
Pain more anteriorly
Possible painful arc and noc ischemia
Usually can reproduce pain when palpating the bicipital groove
Bicipital tendinitis- Yeargason and Speeds test
management of tears
If the patient is a surgical candidate- MRI. If not, conservative management
Usually manage pain with NSAIDS, PT. Can do PT for small tears. Large tears repaired.
If suspect tear- ortho consult. Want timely repairs before atrophy sets in for patients who would have good surgical outcomes.
Constitutional or systemic symptoms accompanying joint complaints: CBC and diff; ESR, serology for rheumatic diseases
Management of Tendinitis/Bursitis
Xray if suspect calcification or SA spur
MRI? – not early on if atraumatic hx
NSAIDS 7-21 day course; Pain relievers
Ice or heat
Positioning and activity education
Cort injections- Misplacement is problem- tendon rupture and necrosis. Ortho consult.
Usually anterior inferior capsule- will report “popping in and out” or disclocation- refer.
Do apprehension test.
Instability is usually mgd by conservative PT and ortho.
Degree of pain varies- protect with sling if recent sublux/dislocations and refer.
Bursitis- Inflammation of bursa
Impingement syndrome/ RC tendinitis-
Irritation of structures above shoulder joint/ under acromion
Due to repeated compression between greater tuberosity and acromion process. Can lead to RC degeneration and tears
Inflammation of the tendon of the biceps brachii
Instability- laxity in the capsule or labral deficiency
Rotator cuff tear- the dynamic stabilizers are disrupted
Arthritis- point tender if AC/SC. Grinding. Age. Postive Cross Arm*- will see in the first step of the Apley Scratch test.