The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments.
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Transcript of The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments.
Derbyshire Sports Injuries Clinic presents
The Shoulder
Shoulder anatomy-bones
Shoulder anatomy-ligaments
Shoulder anatomy-muscles
Shoulder anatomy-bursae
The gleno-humeral jointBall & socket joint which is inherently unstable
due to a shallow socket. Additional stability is provided by:
Static:GH ligaments, labrum & capsule and Dynamic constraints: rotator cuff & scapula
stabilising. The RC muscles act as humeral depressors and centre the humerus in the joint. They work in opposition the deltoid and prevent the humerus rising up and impinging on the undersurface of the acromion
Other joints involved in shoulder movementAcromio-clavicularScapulo-thoracicSterno-clavicularThe smooth movement of all of the joints
together is called ‘Scapulo-humeral rhythm’.Upward rotation of the scapula ensures the
coracoacromial arch is removed from the path of the upwardly elevating humerus
This also enhances stability at >90° by placing the glenoid fossa under the humeral head
Causes of shoulder pain1. Rotator cuff
musculature2. Instability3. Stiffness4. AC joint5. Referred pain
Rotator cuffAcute, chronic or
acute on chronicAcute: muscle
strains, partial or complete tendon tears
RC tendon injuries frequently present as impingement
InstabilityPain from instability can arise from the
anterior, posterior or superior shoulder capsule and labrum.
Glenoid labral lesions may occur either acutely or as a repetitive injury
Can be observed in people who have recurrent episodes of dislocation or subluxation
Initially instability causes symptoms like impingement or joint pain
AC JointOften mistaken for shoulder painIs actually very specific pain and symptoms
are localised on questioning
Shoulder stiffnessCan be from:
TraumaPost-surgicalInjury to the cervical nerve roots
and/or brachial plexusSpontaneously for no reason...
Adhesive capsulitis
Referred painVery common referral
site from the cervical spine, upper thoracic spine and associated soft tissue:Levator scapulaeTrapeziusRotator cuff muscles
TumoursAxillary vein thrombosisPerforated duodenal
ulcer
Patient walks in c/o shoulder painWhere is the pain?How long have you had the pain?Is there a mechanism of injury?Sport?Work activity?Any neck pain, headaches, pins and needles,
numbness, breathing difficultiesPopping in/ out?Night pain is common in impingement and RC
issues but other red flags should be screened for
Clinical pearlsIn acute injuries the position of the shoulder
when injury takes place is important:Arm wrenched backwards in a vulnerable
position: suspect anterior dislocation or subluxation
Fall onto the point of the shoulder: AC jointFall on outstretched arm: SLAP or Bankhart tear
In chronic injuries the position that hurts during activity is important to ascertain
Assessment of the shoulderActive + passive movements:
FlexionExternal rotation: arms by side and 90° abductionInternal rotationHorizontal flexion
Resisted movements:External rotationSubscapularis lift off testDeltoidSupraspinatus- ‘Empty can test’-scaption & internal
rotationBiceps- ‘Speed’s test- supination through range
Special testsAC joint
Compression ‘Scarf test’: horizontal flexion
Impingement:Neer’s: Full flexion EORHawkin’s and Kennedy’s: flex to 90° and internally rotate
Instability:Load and shift test: sitting, distract and move anteriorly
and posteriorlyAprehension test: supine abduct and externally rotate
shoulder, posterior translation of the shoulder relieves dislocation apprehension, anterior translation exacerbates it
SLAP test: O’Brien’s test- pronation resisted
ImpingementThe theory is that the
impingement occurs when the rotator cuff tendons are impinged as they pass through the subacromial space
(the space formed between the acromion, coracoacromial arch and AC joint and the glenohumeral joint below)
The impingement causes mechanical irritation of the rotator cuff tendons and may result in swelling and damage to the tendons
Diagnoses associated with rotator cuff impingementSubacromial bone spurs and/ or bursal
hypertrophyAC joint arthrosis and/ or bone spursRotator cuff diseaseSuperior labral injuryGlenohumeral internal rotation deficit (GIRD)Glenohumeral instabilityBiceps tendinopathyScapular dyskinesisCervical radiculopathy
Types of impingementPrimary external impingement:
Encroachment of the space due to acromion shape, either congenital or due to spurs
Secondary external impingement:Due to inadequate muscular stabilisation of the
scapula or weakness of the rotator cuff muscles creating a muscle imbalance
Internal impingementImpingement of the RC occurs against the
posterior-superior surface of the glenoid, eventually causes damage to the labrum
Rotator cuff injuries CommonRotator cuff tendon becomes swollenPain with overhead activitiesOften associated instability... Symptoms of recurrent
subluxations and ‘dead arms’Painful arc between 70°-120°MRI is assessment tool of choicePatients respond well to physiotherapy: must correct the
imbalances causing the injuryOne single corticosteroid subacromial injection also
shows good evidence of efficacy if in conjunction with rehabilitation
Calcific tendinopathy can occur (idiopathic), seen on X-ray/ ultrasound
Glenoid Labrum tearsSuperior aspect of the glenoid labrum is
the attachment site for the tendon of the long head of biceps (LHB)
Injuries to the labrum areSLAP: extend from anterior to the biceps
tendon to posterior to the tendon. There are 4 types of SLAP lesions.
SLAP tears are stable or unstable depending on how much of the biceps tendon is attached to the glenoid margin
Non-SLAP lesions include degenerative, flap, vertical labral tears and unstable Bankart lesions.
SLAP tearsRepetitive throwing overheadFall on outstretched armPain is poorly localized, worse with overhead
activitiesPopping, grinding, catching are often presentBiceps is often tender on palpation and on
testingMR arthrography is the test of choiceAll unstable labral tears require surgery
Dislocation of the GH jointAnterior dislocation due to excessive abduction/
external rotationMost result in a bony Bankart lesion or a Hill-
Sach’s lesion (fracture of the humeral head posteriorly)
Acute trauma is always the causeMost have a sensation of ‘popping out’Dislocated shoulders should be X-rayed prior to
reduction if possible as a fracture can be presentThe arm should not be put in a sling, but needs
resting at night in external rotationSurgical results are good with only 10% re-
dislocation, whereas non-surgical patients have very high re-dislocation rates
Shoulder instabilityCommon in people with general laxityAnterior instability: mainly post-traumatic but
can also be with capsular laxityPain is usually due to RC tendon impingementX-ray should be done to exclude any fracture
associated with instability. Posterior instability is normally associated
with multidirectional instability
Adhesive Capsulitis Usually between 40-60 years of age More commonly the left?? More prevalent in women More common in diabetics, thyroid disorders and users of
matrix degradation inhibitors Shoulder becomes stiff in the ‘capsular pattern’ of limitation of
abduction < external rotation <internal rotation Post-surgical stiffness usually resolves in a year Idiopathic Adhesive capsulitis normally resolves within 2.5 years Surgical interventions are not very successful, steroid injections
give some patients relief (particularly if done under X-ray, into the joint), physiotherapy helps some patients, and although range of movement is temporarily restored, an MUA often has a poor outcome.
Clavicle fracturesMost common fracture seen in sport... Usually a fall onto the
point of the shoulder or direct contact.Usually fractures in its middle 1/3rd with the outer fragment
displacing inferiorly and the medial fragment superiorlyVery painful!Localized tendernessSwellingBony deformityPrinciple treatment is pain relief, figure of 8 bandage can be
used. During the first 4-6 weeks shoulder flexion is restricted to 90°
Distal clavicular fractures must be referred for an orthopaedic consult for assessment and management
AC joint injuriesUsually results from a fall onto
the point of the shoulderGrading system of injuries is I-
VISurgery is suggested for
Grade IV-IV and Grade III’s that fail conservative treatment (Grade III onwards presents with increasing amount of deformity and should be referred for an orthopaedic consult.
AC joint injuries are easy to diagnose with a diagnostic LA
Chronic AC joint painRepeated minor injuries to the joint after a
previous AC injury which aggravates the already damaged meniscus of the AC joint
Osteolysis can be seen at the edge of the AC joint
X-ray shows marked osteoporosisPhysio, corticosteroid injections and in some cases surgery is needed.
Referred painCx and Tx spine refer to the shoulderAlso, a sore shoulder can refer to the scapula and
upper trapezius area.Trigger points in the neck and scapula muscles
have active referral areas to the shoulderAdverse neural tension/ restricted neural
dynamics can have a major part to play in shoulder pain
Don’t missRuptured LHBPec Major tearNerve entrapments:
Suprascapular nerve: C5,6- wasting of infraspinatus, supraspinatus, vague deep ache
Long thoracic nerve palsy: C5,6,7- serratus anterior palsy. This is the backpack injury!
Books to stand you in good steadClinical Sports
Medicine 4th edition: Brukner & Khan
Orthopaedic Physical Assessment 5th edition: David J Magee