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SHOULDER PATHOLOGIES. IMPINGEMENTS PRIMARY- outlet obstruction (AC osteophyte, thickened bursa esp in RA, swelling/Ca deposits on RC tendon, #humerus,

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Presentation on theme: "SHOULDER PATHOLOGIES. IMPINGEMENTS PRIMARY- outlet obstruction (AC osteophyte, thickened bursa esp in RA, swelling/Ca deposits on RC tendon, #humerus,"— Presentation transcript:

1 SHOULDER PATHOLOGIES

2 IMPINGEMENTS PRIMARY- outlet obstruction (AC osteophyte, thickened bursa esp in RA, swelling/Ca deposits on RC tendon, #humerus, hooked acromions) PRIMARY- outlet obstruction (AC osteophyte, thickened bursa esp in RA, swelling/Ca deposits on RC tendon, #humerus, hooked acromions) SECONDARY- instability or muscle weakness (capsular lax/tightness, mm fatigue, imbalance force couples, spinal stiffness) SECONDARY- instability or muscle weakness (capsular lax/tightness, mm fatigue, imbalance force couples, spinal stiffness)

3 ROTATOR CUFF TEARS STAGE 1- reversible edema, <25yrs STAGE 1- reversible edema, <25yrs STAGE 2- fibrosis + tendinitis 25-40yrs STAGE 2- fibrosis + tendinitis 25-40yrs STAGE 3- bony spurs + tendon ruptures >40yrs STAGE 3- bony spurs + tendon ruptures >40yrs STAGE 4- shoulder arthropathy (4% cuff tears) STAGE 4- shoulder arthropathy (4% cuff tears)

4 CLASSIFICATION SHOULDER DYSFNXS GROUP 1- impingement >35yrs GROUP 1- impingement >35yrs GROUP 2- impingement + instability < 35yrs GROUP 2- impingement + instability < 35yrs GROUP 3- impingement + instability born loose (have mm control if just hypermobile) GROUP 3- impingement + instability born loose (have mm control if just hypermobile) GROUP 4 anterior instability torn loose GROUP 4 anterior instability torn loose

5 IMPINGEMENTS DEEP IMPINGEMENTS – inside of mms impinged, try relocation test, if pain improves, then likely deep/SLAP. More likely to result in eventual SLAP lesion. DEEP IMPINGEMENTS – inside of mms impinged, try relocation test, if pain improves, then likely deep/SLAP. More likely to result in eventual SLAP lesion. weakening and laxity anterior structures- repeated anterior/superior translation HH with HF and overhead- shortening post capsule- undersurface cuff tear- SLAP- complete RC tear weakening and laxity anterior structures- repeated anterior/superior translation HH with HF and overhead- shortening post capsule- undersurface cuff tear- SLAP- complete RC tear

6 IMPINGEMENTS- TESTS NEERS- forced elevation of humerus whilst holding other hand on top shoulder girdle NEERS- forced elevation of humerus whilst holding other hand on top shoulder girdle HAWKINS- 90 flexion and forcibly internally rotated (support on top shoulder girdle) HAWKINS- 90 flexion and forcibly internally rotated (support on top shoulder girdle)

7 INSTABILITY TESTS GROSS GROSS ANTERIOR INSTABILITY- apprehension POSTERIOR INSTABILITY- post instab test INFERIOR INSTABILITY- sulcus test SUBTLE SUBTLE DRAWER- load and shift tests ANTERIOR INSTAB- relocation INTERNAL IMPINGEMENT- relocation

8 ANTERIOR INSTABILITY HILL SACHS DEFECT- posterior lateral HH strikes rim of glenoid at time of disloc HILL SACHS DEFECT- posterior lateral HH strikes rim of glenoid at time of disloc BANKHART LESION- avulsion capsule and labrum from glenoid (traumatic avulsion) BANKHART LESION- avulsion capsule and labrum from glenoid (traumatic avulsion) Both common with anterior instability In 90 abd, incr ext rot, decr int rot (and if int rot tight, will use scap protrxn thus vicious cycle)

9 ROTATOR CUFF TEARS STAGE 1- oedema STAGE 1- oedema STAGE 2- tendinosis STAGE 2- tendinosis STAGE 3- tear STAGE 3- tear Active mvts such as an arc of pain, HBB and HF decr and decr EOR flex are not indicative of one or the other stage- general Active mvts such as an arc of pain, HBB and HF decr and decr EOR flex are not indicative of one or the other stage- general

10 RC TEARS SMALL TEARS- often missed in young people, only picked up when, despite other S&S improving, lat rot remains weak SMALL TEARS- often missed in young people, only picked up when, despite other S&S improving, lat rot remains weak LARGE TEARS- generalized weakness and night pain LARGE TEARS- generalized weakness and night pain

11 ROTATOR CUFF TEARS 3 SIGNS: 1. POSTERIOR CUFF TIGHTNESS 2. EXT ROT 90/90 WEAKNESS 3. SCAPULAR DYSRHYTHMIA

12 ROTATOR CUFF TEARS MISINTERPRETATIONS: - ABDUCTION STRONG BUT EXT ROT WEAK: Supraspin tear (for abd you need deltoid and RC, if strong enough, you wont pick it up- RC substitutes) - INTERNAL ROT- poor test, unlikely - EMPTY CAN TEST - ISOLATING EXT + INT CUFF MMS

13 ROTATOR CUFF TEARS: MISINTERPRETATION - Complex interaction shoulder synergists - Interdigitation rotator cuff near insertion Tear size only really indicated by strength of Ext Rot (statically tested, resistance), is inversely prop and tests post cuff w no other mm substit Tear size only really indicated by strength of Ext Rot (statically tested, resistance), is inversely prop and tests post cuff w no other mm substit Testing Abd and Int Rot appear to have very little clinical value in tears Testing Abd and Int Rot appear to have very little clinical value in tears

14 RC TEAR- RESISTED STATIC EXT ROT STRONG EXT ROT- Rx conservatively STRONG EXT ROT- Rx conservatively WEAK EXT ROT- investigate further (ultrasound) WEAK EXT ROT- investigate further (ultrasound) STRENGTH GOOD, BUT DECR ROM ALL DIRECTIONS- frozen shoulder/capsule (COMMON IN DIABETICS) STRENGTH GOOD, BUT DECR ROM ALL DIRECTIONS- frozen shoulder/capsule (COMMON IN DIABETICS)

15 SLAP LESIONS ‘SLAP’ = SUPERIOR LABRAL INJURIES: SUPERIOR LABRUM ANTERIOR POSTERIOR ‘SLAP’ = SUPERIOR LABRAL INJURIES: SUPERIOR LABRUM ANTERIOR POSTERIOR - Biceps tendon also attaches to ant, post + sup labrum - Usually SLAP diagnosed by exclusion and arthroscopy - ‘dead arm syndrome’: weakness and numbness with overhead activities

16 SLAP- HOW? - Fall outstretched hand in abd - Direct blow to shoulder - TRACTION INJURY - Subluxation or dislocation - Repetitive overhead activities - Lifting heavy objects - Sudden violent biceps contraction….

17 SLAP- HOW?? - Repeated eccentric biceps contraction (deceleration) - TESTS: 1. O’BRIENS 2. CRANKS Arthroscopy confirms it

18 AT RISK FOR SLAP LESIONS Ppl with posterior type II SLAP and internal impingement pre-injury Ppl with posterior type II SLAP and internal impingement pre-injury Tight posterior capsule, anterior instability with decr int rot, incr ext rot (when doing ext rot, biceps in line w labrum, w incr ext rot labral disruption occurs, also pinching inf RC with the protrxn of the scapula (internal impingement). Tight posterior capsule, anterior instability with decr int rot, incr ext rot (when doing ext rot, biceps in line w labrum, w incr ext rot labral disruption occurs, also pinching inf RC with the protrxn of the scapula (internal impingement). TIGHT POST CAPSULE, POOR SCAP CONTROL TIGHT POST CAPSULE, POOR SCAP CONTROL

19 SLAP LESIONS- S&S GIRD (loss of int rot, incr ext rot) GIRD (loss of int rot, incr ext rot) SICK scapula (abducted, ext rot, tipped anteriorly) SICK scapula (abducted, ext rot, tipped anteriorly) Instability, RCS, biceps pathology Instability, RCS, biceps pathology Posterior pain Posterior pain Incr pain w throwing and lying on it Incr pain w throwing and lying on it Popping, locking, grinding, catching, need to move Popping, locking, grinding, catching, need to move ?decr ROM and strength? ?decr ROM and strength?

20 SLAP LESION TESTS RELOCATION TEST- 90/90 pain incr w ext rot and pa on HH RELOCATION TEST- 90/90 pain incr w ext rot and pa on HH ACTIVE COMPRESSION TEST/O’BRIENS- 90 flex, 15 add, int rot, pt flexes and abd against R. Incr pain +, decr w ext rot.. ACTIVE COMPRESSION TEST/O’BRIENS- 90 flex, 15 add, int rot, pt flexes and abd against R. Incr pain +, decr w ext rot.. CRANK TEST- 90 abd, axial load applied whilst slowly taken into int rot. + if catching or grinding pain CRANK TEST- 90 abd, axial load applied whilst slowly taken into int rot. + if catching or grinding pain

21 BICEPS TESTS SPEEDS TEST- flex sh against R with elbow extended and hand fully supinated SPEEDS TEST- flex sh against R with elbow extended and hand fully supinated YERGASONS TEST- sh neutral, elbow 90 flex, resist supination from full pronation YERGASONS TEST- sh neutral, elbow 90 flex, resist supination from full pronation

22 CALCIFYING TENDINITIS/BURSITIS Pain over deltoid area Pain over deltoid area Arc of pain Arc of pain Decr ROM Decr ROM Night pain Night pain Atrophy Atrophy REST, NSAID, AVOIS IMPINGEMENT POSITIONS, GENTLE ROM, AVOID HEAT REST, NSAID, AVOIS IMPINGEMENT POSITIONS, GENTLE ROM, AVOID HEAT

23 GENERAL Anterior pain often local pathology Anterior pain often local pathology Posterior pain: inside impingement or referred from Cx or Tx Posterior pain: inside impingement or referred from Cx or Tx Watch out for distal anaes/paraesthesia Watch out for distal anaes/paraesthesia Pattern of movement gives vital clues Pattern of movement gives vital clues Slipping, popping/snapping, clicking/jamming/catching, dead arm: INSTABILITY OR LABRAL TEAR Slipping, popping/snapping, clicking/jamming/catching, dead arm: INSTABILITY OR LABRAL TEAR Crepitus- RC and AC joint Crepitus- RC and AC joint Grinding- OA Grinding- OA

24 GENERAL- KIBLER KINETIC CHAIN Check your lower limbs, backs, knees, ankles, etc. Usually there is a problem in the opposite leg to the painful shoulder (esp with medial rotation of the hip). Check your lower limbs, backs, knees, ankles, etc. Usually there is a problem in the opposite leg to the painful shoulder (esp with medial rotation of the hip). Check one leg balance, squats, joint ROM LLs, core stability etc Check one leg balance, squats, joint ROM LLs, core stability etc Never forget Lats Dorsi- major reason for decr int rot and incr protrxn scap Never forget Lats Dorsi- major reason for decr int rot and incr protrxn scap

25 CERVICAL SPINE C4-6 C4-6 ULTT ULTT MOBILITY AND HEAD POSITION MOBILITY AND HEAD POSITION LEV SCAP! LEV SCAP! R1 AND SCALENAE! R1 AND SCALENAE! TX SPINE AND COSTOVERT!!! TX SPINE AND COSTOVERT!!!

26 QUICK ESCAPE NO TRANSLATOR 1. Watch undress 2. Assess posture- not just shoulder 3. Watch carefully bilat and unilat abduction short or long lever 4. Decide whats weak/hyperactive (remember stabilizers and movers) 5. Palpate all suspected mms and release 6. Test posterior capsule and stretch

27 QUICK ESCAPE NO TRANSLATOR 1. Release and needle mms 2. Stretch capsule 3. Mobilize Tx and Cx if needed 4. Strap- various ways 5. Setting of scap, turning on cuff ex’s and core stability ex’s (NO RESISTANCE OR LARGE MVTS!), neck stretches 6. Kinetic handling!!!!!!!!!!!!!!


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