Shoulder Flashcards
(31 cards)
shoulders are complex
} Lots can go wrong and numerous structures can cause shoulder pain
} To assess and treat shoulders effectively you need to
} Understand the anatomy } Joints
} Muscles
} Ligaments etc
} Understand the complexity of movement and control } Joint interactions
̈ Any painful or weak link can decrease effectiveness of shoulder function } Complex co-operative muscle interactions
̈ Any single weakness can disrupt kinetic sequencing } Be able to effectively differentially diagnose
} Assessment is the key!!!
4 joints of the shoulder
} Sternoclavicular } Acromioclavicular } Glenohumeral } Scapulothoracic } All 4 joints work co- operatively } ROM largely produced by ST & GH...
sternoclavicular joint
} Clavicle → mechanical strut for scapula through its attachment to sternum
} Links axial skeleton to appendicular skeleton
} Primary purpose → position scapula optimally to receive head of humerus
} Highly stable – ligamentous structure
} Injury due to large forces } Commonly = fracture
BUT
} Potential SC joint dislocation ̈ Anterior vs posterior….
acromioclavicular joint
} Stabilised by
} Superior & inferior acromioclavicular
joint capsular ligaments
} Coraclavicular ligament
} Articular disc (of varying form, mostly present)
} Deltoid & upper trapezius muscles
} Proposed rotational adjustment
motions
} Optimally aligns scapula against thorax
} Adds to scapula motion
} Clinically important – don’t neglect!
glenohumeral joint
} Multiaxial synovial joint } Design favours mobility over stability } Producing extensive ROM with ST } Bony fit offers little to no stability } Glenoid fossa covers approx 1/3 HOH } * Mechanical integrity maintained by muscles and capsular ligaments
glenohumeral joint
} Provided by:
} Joint capsule & capsular ligaments
} Inherently loose capsular ligaments
̈ superior GH, middle GH, inferior GH ligs (esp ant & posterior bands in functional abd position)
} Reinforce capsule to assist maintenance of negative intra- articular pressure
} Taut in varying positions → please review!
} Coracohumeral ligament } Glenoid labrum
} Expands glenoid cavity } Rotator cuff muscles
} LH biceps brachii
scapulothoracic joint
} Specific ST ROMs
} BUT important element of overall shoulder biomechanics } Essential involvement in GH ROM & overall shoulder function
scapulohumeral rhythm
• *If there is one movement you can assess well…
• Consider ALL joints & relevant muscles
• Overall ratio of 2:1 = GH:ST
• Initial movement = purely GH
• Clavicle retracts & posteriorly rotates
• Scapula tilts & ER
• GH ER
• Why??
• Supraspinatus contracts - taut superior
capsule & depression of HOH
• Auxillary pouch stretches → inferior
sling for HOH
GH joint muscles
} Glenohumeral joint } Deltoid } Anterior, middle & posterior } Coracobrachialis } Biceps brachii } Latissimus dorsi } Pec major \+ } Rotator cuff
rotator cuff musculature
} Supraspinatus (!!!)
} Superior roll of HOH
} Compression into fossa
} Restricts superior translation
} Infraspinatus, teres minor, subscap } Depression force on HOH
} Infraspinatus, teres minor
} External rotation of humerus
abduction
} *Counteract pull of deltoid → elevation of HOH } Deltoid vs suraspinatus injury
} Consider ability to abduct...Scapulothoracic joint muscles
} Elevators
} Upper trapezius
} Levator scapulae } Rhomboids
} Depressors
} Lower trapezius
} Latissimus dorsi } Pectoralis minor } Subclavius
} Protractors
} Serratus anterior
} Retractors
} Middle trapezius
} Rhomboids
} Lower trapezius
} Upward rotators
} Serratus anterior
} Upper & lower trapezius
} Downward rotators } Rhomboids
} Pectoralis minor
Shoulders are tricky
} Difficult to differentially diagnose
} Complex joint interplay
} Complex co-operative muscular control
} Special tests often don’t have high specificity & sensitivity
} Regularly painful > 90o
} Mechanical vs non-mechanical pain
} Pain can be referred from other regions
} May not be MSK issue BUT due to more serious problem…
} Some tips for success
} Be thorough in your history taking } Assess effectively
} Get your patient to do their work!
Hx
} Try to pinpoint the site of pain
} Easier said than done!
} AC & bicipital pain often localised
} Define pain
} Type, severity…
} Sensation } Neural
} Referred
} “Dead arm” – baseball pitchers → labral injury
} Onset of pain
} Acute or insidious
} If MOI
} Shoulder position provides clues to structures injured
} Night pain common in some presentations
} Aggravating & easing
} Impact on ADLs
PE
} Takes the usual form and covers all bases } LOADS of special tests to choose from…
} Diagnose effectively
} What is your hypothesis?
} What are your differential diagnoses?
} What is contributing to the pain and presentation? } All joints and muscles!!!
6 categories of shoulder pain
} Rotator cuff (including impingement) } Labral injury } Instability } Stiffness } AC joint pathology } Referred pain } Cx } Tx } Visceral } Nerve lesions: e.g suprascapular nerve, axillary nerve, long thoracic nerve
referred pain from viscera
} Cardiac dysfunction
} Diaphragm dysfunction, lung disease
} Pneumoperitoneum/Perforated ulcer } Disease of the oesophagus
} Aneurysm of the subclavian artery
} Gallbladder and spleen (left shoulder) } Axillary vein thrombosis
differential Dx
} Pancoasts tumor – pulmonary apex, non small cell Ca
} Bone tumor (young) } More commonly 2o
referred pain
} Commonly } Cx spine } Tx spine } Associated musculature... BUT } Shoulder dysfunction can alternatively result in } Traps pain and fatigue } Pain radiation into } Neck } Posterior scapula } Upper arm } Forearm } Wrist and hand
rotator cuff pathology
} One of the most common shoulder problems you will treat } Supraspinatus most commonly affected } Tendinopathy } As per tendon continuum... } Calcification may occur } Most commonly within supraspinatus } Investigation of choice } MRI } Alternatively US
Rotator cuff pathology clinical presentation
} Pain often considerable } Rest } Seemingly minor movements } Night } Potential for associated instability & “dead arm” } Pain with overhead activities } < 90o painfree } Painful arc – 70-120o } Catch/difficulty on return } TOP supraspinatus tendon at insertion point } If supra tendinopathy.... } ↓ IR – consider HBB ROM... } Pain on } Empty can > full can } Impingement tests } EOR passive flexion
impingement syndrome
} Impingement syndrome - ?overuse, tendinopathy of supraspinatusàpainàRC muscle dysfunctionàpotenital bursitis
} 3 types of impingement
} 1 ̊ External
} Encroachment of subacromial space from superior structures } Spurs may be seen on X-Ray
} 2 ̊ External
} Inadequate muscle stabilisation of scapula
} Internal (glenoid)
} Overhead sports à undersurface of RC against posterosuperior surface
of glenoid during late stage cocking,
̈ Overuse may cause pathological process and superior labrum injury
Rx and rehab for impingement
} Pain relief } Mobilisation, STT, medication... } Correction of abnormalities } GH instability } Muscular weakness and imbalances } ST tightness } Posterior capsule tightness } Impaired scapulohumeral rhythm } Correct training errors or functional errors
Labral lesions
} Excess traction on labrum through LHB } FOOSA
} Classification
} SLAP – stable vs unstable, 4 grades
} Non-SLAP – degenerative, flap, vertical labral tears, Bankart
} Bankart – unstable lesion anterior inf labrum, repetitive dislocations } Hill-Sachs – damage to posterior humeral head
Labrum assessment and management
} Clinical presentation SLAP } TOP anterior shoulder
} Pain on resisted biceps contraction – Dynamic labral shear, O’Brien’s
} Management
} Stable SLAP/nonSLAP = arthroscopic debridement
} Unstable SLAP/non-SLAP = arthroscopic fixation
} Conservative: >50 yo; young, minor SLAP; ?non-overhead sports
} NSAIDs, scapula stabilisers/dynamic stabilisers, capsule stretching } AVOID heavy weights early
