Shoulder disorders

TOS

Thoracic outlet syndrome Compression of brachial plexus in 95% of cases, or compression of blood vessels to UE in less than 5% of the cases. -Compressed by: presence of cervical rib, Abnormal long C7 transverse process, old Fx of clavicle, repetitive overhead activities, wearing heavy load on shoulder, poor posture causing tightness and boney alignment to include droopy shoulder. - commonly preceded by cervical hyperextension injury

Acromioclavicular joint (ACJ): Sprains, sublaxations, dislocations (Shoulder separations)

Typically caused by FOOSH or fall on point of shoulder (superior-lateral) with arm at side (ADD)

The rotator cuff is formed by the tendons of which muscles?

"SITS" Supraspinatus Infraspinatus Subscapularis Teres Minor

2 types labral tears and MOI

1. Bankart lesion- Anterior-inferior tear or avulsion of the glenoid labrum from rim to cavity. Can also be a "Bony Bankart" MOI- anterior GH dislocation/sublax and instability 2. SLAP Bankart (Superior Labral Anterior to Posterior)- can involve long head of biceps tendon MOI- fall onto ABD or fully extended arm, resulting in pinching the superior labrum b/t humeral head and superior glenoid. Traction injury avulsing the biceps anchor especially if contracted Chronic overuse (most common)- repetitive movements of overhead activities, throwing, superior compression (head into glenoid), peel-back mechanism- superior-posterior compression during cocking phase of throw.

2 surgical interventions used after anterior GH dislocation Bankart

1. Bankart- reattaching the labral tear to the bone.

5 injuries associated with anterior GH dislocations

1. Bankhart lesion- tear or avulsion of glenoid labrum. If a fragment of bone avulses off the cavity, it is a "Bony Blankhart" 2. Hill Sachs- Posterior-lateral humeral head defect. Compression Fx caused by posterior-humeral head hitting the inferior glenoid rim 3. Axillary nerve damage- nerve stretched by humeral head resulting in atrophy and weakness of deltoid and teres minor muscles 4. Chronic GH instability- dislocation stretches the anterior capsule, ligaments, and rotator cuff musculature of young patients. Recurrence rates: <20 yrs- 90% 20-25 yrs- 50-75% >40 yrs- 20% 5. Rotator cuff tears- GHJ dislocation tears soft tissue in older patients that is only stretched in younger patients. patients older that 40 yrs have higher rates of RC tears following dislocation: >40 yrs- 15% > 60 yrs- 40%

2 surgical interventions used after anterior GH dislocation: Capsular Shift

2. Capsular shift- Cutting, overlapping and then suturing the anterior capsule and ligaments together making a tighter capsule.

Direction of GH dislocation that is most common, positional force in combination that creates MOI for the GH dislocation

Anterior combination of ABD, ext rot, and extension

Etiology, signs and symptoms of AC sprain

Caused by FOOSH, or fall on point of shoulder with arm at side. Signs and symptoms: Edema, erythema, warmth, point tenderness at AC joint. Crepitus at AC joint Pain with passive, active, and/or resisted HzADD Painful arc in ABD around 140-180 degrees distal clavicle may ride above acromion Pain and visible reduction of "bump" with manual pressure on the DISTAL CLAVICLE (difference between SC joint) Visible separation on X-rays

Fx seen in shoulder complex: Proximal Humerus

Common injury from direct blow or FOOSH in the greater or lesser tuberosity, surgical neck, or shaft. Treatment for non-displaced-immobilization Treatment for displaced- ORIF Rehab- AROM wrist, hand immediately GH PROM/AAROM and AROM based on stability of Fx/bony union. Isometric and progression per Fx stability.

Mumford procedure

Distal resectioning (shaving) off of the clavicle. Used to treat DJD/AC joint

Weaver- Dunn procedure

Done for those grades IV-VI Distal resection of the clavicle (Mumford) and a looping of the coracacromial ligament around the distal clavicle to hold the clavicle in place.

Mumford procedure

Done for those with DJD of the AC joint. Shaving off the clavicle

What are signs and symptoms of SC sprain

Edema, erythema, warmth, point tenderness at SC joint. Pain is increased with supine Pain with UE motions that effect SC joint. Visible displacement

Adhesive capsulitis etiology, and signs and symptoms

Frozen shoulder. Contracture within GHJ capsule w/ a resultant limitation in active and passive motion. Etiology- poorly understood but may develop spontaneously or post-traumatic, have initial inflammation leading to adhesions and fibrosis that occur in the inferior capsule. Signs/symptoms- Pn w/ shoulder motion, loss of PROM/AROM in ER, ABD, IR. No GH motion, only scapular motion. - Painful phase-1-3 mos, excessive pn -Freezing phase- 3-9 mos, limited motion & pn -frozen phase-9-15 mos or longer, limited motion, reduced pn - thawing phase- 15-24 mos, returning to motion

Fx seen in the shoulder complex: Clavicle

Fx common in childhood, <25 yrs from direct trauma, FOOSH, collision sports. Located-mid clavicle. Treatment for non-displaced- Immobilization 6-8 wks Treatment for displaced- Surgical reduction using plates/screws Rehab- AROM elbow, wrist, hand immediately. Shoulder ROM & strengthening based on Fx stability/bony union.

Acromioclavicular joint (ACJ): Sprains, sublaxations, dislocations (Shoulder separations)

Injury class: Grade I- Sprain of AC ligament only Grade II- Rupture of AC ligament, sprain of CC ligament, slight increase of joint space. (may look like a step) Grade III- Rupture of AC and CC ligaments, increased space superiorly 25-100% more than normal shoulder.

Bicipital tendonitis

Irritation and/or inflammation of long head of biceps in bicipital groove. -from overuse of repetitive lifting and throwing - results from impringement of biceps long head tendon against coracoacromial arch.

What is MDI? How is it treated?

MDI- Atraumatic multidirectional instability (GHJ) treatment- Conservative- rehab focusing on strength and neuromuscular control of the dynamic shoulder stabilizers (RC, deltiod, pec major, and scap muscles). Open and closed chain used. Surgical- inferior capsule shift, followed by post-operative rehab per established protocols. Tightened inferior capsule decreases mobility of GHJ in all directions.

Myofascial pain syndrome and treatment

Painful muscle condition developed with "trigger pts" that are mainly in scapular muscles. Associated with tightness/spasm (due to decreased blood flow) and rope-like thickening of muscle tissue. treatment- inflammation reduction- modalities, NSAIDS, and activity modification. Also steroid injections at trigger sites. -myofascial release techniques -*Postural correction exercises* -*Muscle strengthening (gradual* - stress reduction/biofeedback

Fx seen in the shoulder complex: Scapula

Rare caused by direct blow or MVA to the body of scapula. Treatment for non-displaced- ice, maybe sling Treatment for displaced- No surgery- musculature keeps bone together Rehab- Immediate AROM elbow, wrist, hand Shoulder ROM & strengthening based on Fx stability/bony union

What muscles are considered scapular stabilizers?

Rhomboids Serratus anterior Trapeziod Levator scapulae

Group of muscles generally strengthened first during rehab of shoulder disorders:

Rotator cuff muscles

Grade II AC sprain

Rupture of AC ligament, sprain of CC ligament, slight increase of joint space.

Grade III AC sprain

Rupture of AC/CC ligaments, increased joint space superiorly 25-100% more than normal shoulder and may include displacement of clavicle.

Sternoclavicular joint (SCJ)

Seldom injured due to strong ligamentous support. MOI- MVA or sports injury

Etiology of subacromial impingement

Soft tissue compressed against coracoacromial arch. Structures that are impinged may be the supraspinatus, infraspin, teres minor and/or long head of biceps tendons and/or subacromial bursa. -The rotational position of the should during impingement will determine which structures are affected. - Supraspinatus tendon is the most impinged.

Grade I AC sprain

Sprain of AC ligament only, ligaments intact, no change in joint space.

Rotator cuff tear

Tear in fibers of RC tendons- most common supraspinatus. End result of chronic subacromial impringement syndrome or trauma (anterior dislocation). Typical in middle-aged to older pts. Signs/symptoms- Pn, tenderness, warmth at subacromial area. Unable to actively ABD or control lowering of arm from overhead. Full passive ROM is available in ABD. <3 cm- treat conservatively- 50% pts gain function with conservative.