6The gleno-humeral joint Ball & socket joint which is inherently unstable due to a shallow socket.Additional stability is provided by:Static:GH ligaments, labrum & capsule andDynamic 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 acromionLabrum deepens the socket by 75% and widens it by 50%
7Other joints involved in shoulder movement Acromio-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 humerusThis also enhances stability at >90° by placing the glenoid fossa under the humeral head
8Causes of shoulder pain Rotator cuff musculatureInstabilityStiffnessAC jointReferred pain
9Rotator cuff Acute, chronic or acute on chronic Acute: muscle strains, partial or complete tendon tearsRC tendon injuries frequently present as impingement
10InstabilityPain 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 injuryCan be observed in people who have recurrent episodes of dislocation or subluxationInitially instability causes symptoms like impingement or joint pain
11AC Joint Often mistaken for shoulder pain Is actually very specific pain and symptoms are localised on questioning
12Shoulder stiffness Can be from: TraumaPost-surgicalInjury to the cervical nerve roots and/or brachial plexusSpontaneously for no reason... Adhesive capsulitis
13Referred painVery common referral site from the cervical spine, upper thoracic spine and associated soft tissue:Levator scapulaeTrapeziusRotator cuff musclesTumoursAxillary vein thrombosisPerforated duodenal ulcer
14Patient walks in c/o shoulder pain Where 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
15Clinical 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 subluxationFall onto the point of the shoulder: AC jointFall on outstretched arm: SLAP or Bankhart tearIn chronic injuries the position that hurts during activity is important to ascertain
16Assessment of the shoulder Active + passive movements:FlexionExternal rotation: arms by side and 90° abductionInternal rotationHorizontal flexionResisted movements:External rotationSubscapularis lift off testDeltoidSupraspinatus- ‘Empty can test’-scaption & internal rotationBiceps- ‘Speed’s test- supination through range
17Special tests AC joint Impingement: Instability: Compression‘Scarf test’: horizontal flexionImpingement:Neer’s: Full flexion EORHawkin’s and Kennedy’s: flex to 90° and internally rotateInstability: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 itSLAP test: O’Brien’s test- pronation resisted
18ImpingementThe 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
19Diagnoses associated with rotator cuff impingement Subacromial 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
20Types of impingement Primary external impingement: Encroachment of the space due to acromion shape, either congenital or due to spursSecondary external impingement:Due to inadequate muscular stabilisation of the scapula or weakness of the rotator cuff muscles creating a muscle imbalanceInternal impingementImpingement of the RC occurs against the posterior-superior surface of the glenoid, eventually causes damage to the labrum
21Rotator cuff injuries Common Rotator cuff tendon becomes swollen Pain 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 rehabilitationCalcific tendinopathy can occur (idiopathic), seen on X-ray/ ultrasound
22Glenoid 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 marginNon-SLAP lesions include degenerative, flap, vertical labral tears and unstable Bankart lesions.
23SLAP tears Repetitive throwing overhead Fall on outstretched arm Pain 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
24Dislocation of the GH joint Anterior 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
25Shoulder instability Common in people with general laxity Anterior 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
26Adhesive Capsulitis Usually between 40-60 years of age More commonly the left??More prevalent in womenMore common in diabetics, thyroid disorders and users of matrix degradation inhibitorsShoulder becomes stiff in the ‘capsular pattern’ of limitation of abduction < external rotation <internal rotationPost-surgical stiffness usually resolves in a yearIdiopathic Adhesive capsulitis normally resolves within 2.5 yearsSurgical 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.
27Clavicle 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
28AC 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
29Chronic AC joint painRepeated minor injuries to the joint after a previous AC injury which aggravates the already damaged meniscus of the AC jointOsteolysis can be seen at the edge of the AC jointX-ray shows marked osteoporosisPhysio, corticosteroid injectionsand in some cases surgery is needed.
30Referred pain Cx and Tx spine refer to the shoulder Also, 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
31Don’t miss Ruptured LHB Pec Major tear Nerve entrapments: Suprascapular nerve: C5,6- wasting of infraspinatus, supraspinatus, vague deep acheLong thoracic nerve palsy: C5,6,7- serratus anterior palsy. This is the backpack injury!
32Books to stand you in good stead Clinical Sports Medicine 4th edition: Brukner & KhanOrthopaedic Physical Assessment 5th edition: David J Magee