1. The Shoulder

2. Passive stability of the shoulder
Ligaments and capsule.

3. Glenohumeral ligaments.
Coracohumeral lig. and Sup. glenohumeral lig.
Prevent inferior subluxation of the shoulder. Coracohumeral also prevents LR in relaxed standing.
Middle glenohumeral lig.
Resists ant. translation in early range of abd.
Inferior glenohumeral lig. (Ant & Post bands)
Ant: Resists ant. translation. Post: Resists inf. translation. Involved at EOR abd. and LR

4. Glenohumeral ligaments
Coracoacromial lig.
Prevents sup. Translation of humeral head.
Degenerative changes often seen on acromial side (never clavicular side) with osteophyte formation.
Coracoclavicular lig.
Clavicle elevation elevates the scapular via this ligament.

5. Rotator Interval Capsule
Gap in the rotator cuff
Thickened part of the capsule
Tightens in frozen shoulder
Restricts extension, external rotation and abduction

6. Negative Intra-articular pressure
An important static stabiliser (Kumar et al 1985)
Changes in relation to joint position (83 mmHg at 20° abd, 10 mmHg at 80° abd)
Patients with severe RC defects have reduced or no NIP.
May not return in patients who have undergone open capsular procedures

7. Active stability of the shoulder
The rotator cuff and biceps

8. The Rotator Cuff
Rotator cuff tendons fuse to form a common insertion on the humeral tuberosities. Clerk and Harryman (1992)
Moves GH jt.
Compresses and centres humerus on the glenoid.

9. Biceps In a cadaver it stabilises the GH jt in abd and LR
Long head resists superior translation
Short head resists inferior translation

10. Trapezius Most fibres of upper traps go to clavicle, not scapula
Middle traps insert primarily to acromion
Lower traps all insert into deltoid tubercle

11. Trapezius
Upper traps have a small CSA, thus thought to have little influence on scapula motion
Middle traps have a stabilising function
Lower traps also stabilise. Insertion into axis of rotation means they cannot produce movement. May upwardly rotate at >90° abduction
Main elevator of the scapula is levator scapula

12. Diagnosis
Imaging etc

13. MRI
Normal RC
RC Tear
Sher et al 1995 (JBJS 77A)
The dominant shoulder of asymptomatic population was assessed by MRI (NB: PTT = Partial thickness tear, FTT= Full thickness tear)
In year olds, 4% have PTT, none had FTT
In year olds, 24% had a PTT and 4% had a FTT
In >60 year olds, 28% had a PTT and 12% had a FTT

14. Ultrasound Milgrom et al 1995 (JBJS 77-B)
US of 90 asymptomatic shoulders (no history of pain) in 6 groups. 40 year olds, 50 year olds etc up to 90 year olds
In 40 and 50 year olds = 5-11% incidence of RC disease
In 60 and 70 year olds = 30-50% incidence of RC disease
In 80 year olds + = 60-80% incidence of RC disease
After the 5th decade of life there is a 55% incidence of asymptomatic FTT

15. % Prevalence of RC pathology
MRI
Frost et al (1999) J Sh Elb Surgery
42 people with SIS (subacromial impingement syndrome) + 31 aged matched controls
RC pathology on imaging: SIS = 55%, Controls = 52%
Related to age:
Age
% Prevalence of RC pathology
31-39
40-49
50-59 32 48 72

16. Suspension Bridge How can you function with a rotator cuff tear?
Burkhart et al 1993: “Suspension Bridge”
Thickenings around the margins of the tear (cable)
Hole gets bigger but as long as cable is attached to the head of humerus, function continues.

17. Posture and Muscle Imbalance
How many patients do you teach and emphasise the benefits of good posture?
Why?
“Good posture is conducive to maximal efficiency and involves minimal strain”
“Is dependent upon ideal alignment and normal balance of muscles”
Bad posture such as the forward head posture FHP, often linked to pain

18. Posture and SIS
“In the patient with FHP, rounded shoulders, increased TxSp kyphosis, the scapula rotates forward and downward, depressing the acromial process and changing the direction of the glenoid fossa so that when the patient attempts to elevate the arm, the supraspinatus tendon and/or the subdeltoid bursa may become impinged against the anterior portion of the acromion process”.

19. Some evidence?
Lewis et al (2005) Journal of Shoulder and Elbow Surgery. Subacromial impingement syndrome: The role of posture and muscle imbalance
Compared posture of symptomatic and asymptomatic people. Looking at various measures for posture
No correlation between posture and symptoms or shoulder range of motion except that people with a FHP had a FSP and people with a FSP had protraction
Subject with most upwardly rotated scapula and that with the most downwardly rotated scapula had similar ranges of movement not flexion ( degrees). They also had similar FHP and thoracic kyphosis.

20. The ‘Cuff’
Impingement?

21. Rotator cuff disease Extrinsic Subacromial impingement
Internal impingement
Subcoracoid impingement
Intrinsic
Rotator cuff pathology

22. Subacromial impingement
Incidence of cuff tears increases with age
Most PTT are either intratendinous or on the articular side of the cuff
Cause of tears is degeneration not repetitive trauma
Tendonosis not tendonitis. Absence of neutrophils (inflammatory cells) in RC pathology. Change from type I (tendons) to type III (skin, scar tissue) collagen (weak). Increased cellularity

23. Causes
Overuse?
Rats who run lots have tendons showing degeneration as with RC disease compared to controls
Diet?
Study looked at 2 groups with RC disease and pain. Gp 1 given fish fatty acids and antioxidants. Gp 2 placebo. Gp 1 had significant reduction in pain and increased activity at 1 month. (Oxidative stress)

24. The role of the bursa
IL-1β secreted by lymphycytes to mediate inflammation
High levels in bursa of patients with RC disease
Also positive correlation between levels of IL-1β and VAS-pain
Maybe pain and blocked movement on elevation is due to bursa inflammation rather than RC entrapment.

25. Managing shoulder pain
Rule no 1: Relative rest. Some authors believe that the only reason SADs work is because of the enforced rest
Electrotherapy is limited. Pulsed US and IFT do not reduce shoulder pain or disability
Acupuncture no better than placebo TENS in reducing shoulder pain or disability
Ultrasound given for 24 treatments over 6 weeks reduces shoulder pain in the presence of calcific tendinitis

26. Manual therapy
Various studies showing significant improvements in strength (Bang and Deyle, 2000) and disability scores (Bergman el al, 2004) compared to controls.
Equal short term and better long term outcomes compared to steroid injection (Hay et al 2003)

27. Rotator cuff rehabilitation
Phase 1
Reduce pain
Maintain Range
Retard muscle atrophy
Maintain and improve other areas influencing the shoulder
54% of shoulder power comes from energy transferred from the lower limbs and pelvis (Kibler, 1995)

28. Rotator cuff rehabilitation
Phase 2
Tendon rehabilitation can take a long time.
Exercise in pain free range and gradually increase…
1: Adduction exs
2: External rotation exs (through abd range)
3: Internal rotation exs (through abd range)
4: Abduction exs
The Shoulder Horn

29. Rotator cuff rehabilitation
Phase 3
Return to function
Progression to functional exercises
Sensorimotor control