Shoulder Joint and Rotator Cuff Injuries

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Questions and Answers

Which of the following is NOT a dynamic stabilizer of the glenohumeral joint?

Rotator cuff muscles

Glenoid labrum (correct)

GH joint movers

Scapular stabilizers

What type of impingement is typically associated with structural variations in the acromion?

Dynamic impingement

Primary impingement (correct)

Internal impingement

Secondary impingement

Which rotator cuff muscle is primarily responsible for internal rotation?

Infraspinatus

Subscapularis (correct)

Teres minor

Supraspinatus

What is a common factor contributing to rotator cuff injury?

Repetitive microtrauma Signup and view all the answers

Which of the following tests is used to assess a rotator cuff tear?

Drop arm test Signup and view all the answers

What is a characteristic symptom of rotator cuff pain that distinguishes it from other shoulder conditions?

Pain that does not radiate distal to the elbow Signup and view all the answers

Which condition is indicated by visible atrophy of the supraspinatus and infraspinatus muscles?

Stage III: Bone spurs and tendon rupture Signup and view all the answers

During rehabilitation, what is the recommended frequency for performing strengthening exercises for shoulder recovery?

Three times weekly Signup and view all the answers

In the management of rotator cuff injuries, which exercise should be prioritized in the early rehabilitation stages?

Pendulum exercises Signup and view all the answers

In a patient with rotator cuff pathology, which action typically leads to increased pain during shoulder range of motion activities?

Lowering the arm from an overhead position Signup and view all the answers

What is the maximum duration of an unsuccessful nonoperative treatment program for rotator cuff issues?

3 to 6 months Signup and view all the answers

What classification of rotator cuff tears primarily focuses on the mechanism of injury?

Based on the underlying pathology Signup and view all the answers

Which symptom is NOT typical for Neer’s classification stage II / III?

Persistent numbness in the arm Signup and view all the answers

Which factor does NOT influence the progression of rehabilitation after rotator cuff repair?

Social support after surgery Signup and view all the answers

In which population is chronic rotator cuff tearing most commonly observed?

People over 50 years with no history of shoulder trauma Signup and view all the answers

What is a noted advantage of early surgical repair for acute rotator cuff tears?

It results in better mobility of the rotator cuff Signup and view all the answers

What is typically assessed in addition to the shoulder girdle during pain management?

Associated cervical and thoracic spine regions Signup and view all the answers

What is the typical treatment approach for chronic rotator cuff tears?

Conservative rehabilitation program Signup and view all the answers

What type of rotator cuff tear indicates complete involvement of the tendon?

Full-thickness or complete tear Signup and view all the answers

Which symptom is often associated with chronic cases and may indicate adhesive capsulitis?

Stiffness and limited range of motion Signup and view all the answers

Study Notes

Shoulder Joint Injuries

The glenohumeral joint is a common injury site in competitive sports.
Dynamic stabilizers include the rotator cuff muscles, scapular stabilizers, and glenohumeral joint movers.
Static stabilizers include bony anatomy, glenoid labrum, capsule, and ligaments.

Rotator Cuff Injuries

Four muscles comprise the rotator cuff: supraspinatus, infraspinatus, teres minor, and subscapularis.
These muscles dynamically stabilize the shoulder throughout its range of motion (ROM).
The infraspinatus, teres minor, and subscapularis depress the humeral head, countering the upward pull of the deltoid.
Infraspinatus and teres minor perform external rotation, while the subscapularis performs internal rotation.

Scapular Dysfunction

Improper positioning of the scapula relative to the humerus can lead to rotator cuff tears due to instability and impingement.

Factors of Rotator Cuff Injury

Impingement syndromes
Repetitive microtrauma
Direct blows
Excessive tensile forces

Impingement Syndrome

Classified as intrinsic or extrinsic.
Intrinsic causes involve acromion derangement, damaging or irritating the supraspinatus tendon.
Extrinsic causes can be primary or secondary.
Primary impingement results from chronic overhead movements (baseball, swimming).
Secondary impingement is caused by muscular imbalance, particularly in overhead athletes.

Clinical Presentation

Impingement syndrome typically presents with anterior superior lateral shoulder pain, exacerbated by overhead movements.
Pain often has a gradual onset, associated with increased training activity or changes to sporting equipment use.
Sleep disturbance is a potential symptom.
Painful arc often felt between 45 and 120 degrees of abduction.
Clinical evaluation involves checking for pain in particular ranges of motion.

Primary Impingement

Crowding of the subacromial space
Hypertrophic degenerative changes of the AC joint.
Thickening or calcification of the coracoacromial ligament
Subacromial bursa thickening and fibrosis
Increased thoracic kyphosis
Structural acromion variations
Trauma (macrotrauma or microtrauma)

Secondary Impingement

Commonly stems from glenohumeral or scapulothoracic instability.
Instability at the glenohumeral joint can arise from excessive demands on the capsule, ligaments, and labrum.
Factors such as fatigue and tendon injury contribute to anterior glenohumeral instability.

Internal Impingement

90° abduction and 90° external rotation position causes posterior and superior rotation of the rotator cuff tendons
Tendons may get pinched or compressed between the humeral head and the glenoid rim.

Diagnosis

Diagnosis is generally made clinically via range of motion tests.
Painful arc, typically between 45 and 120 degrees of abduction, suggests impingement.
Manual strength testing assesses potential weakness, particularly in abduction, internal, and external rotations.

Special Tests

Neer test, full/empty can tests(supraspinatus), drop arm test, and Hawkins impingement test are used to assess for impingement.

Neer's Classification

Stage I: Edema and hemorrhage (usually in patients <25 years)
Stage II: Tendinitis/bursitis and fibrosis (typically in patients 25-40 years)
Stage III: Bone spurs and tendon rupture (common in patients >40 years old)

Early clinical stages & symptom notes

Aching after use only
Painful arch during abduction (60° to 120°)
Pain-free passive movements
Clinicians rarely see patients during this stage

Activity Modification

Avoid impingement positions during activities of daily living (ADLs) and training.
Avoid poor postures.
Ice therapy after workouts
Ensure scapular dynamic stability
Maintain correct exercise positions
Regular evaluation of pain, muscle strength, and range of motion (ROM)

Later Stage Interventions

Regular ROM and stretching exercises.
Strengthening exercises (3 times weekly).
Modalities (heat or cold).
Manual therapy.
ROM exercises (e.g., shrugs, shoulder retractions, pendulum exercises).
Scapular retraction specific exercises.

Progress to Active Assisted Motion

Cane, suspended pulleys or uninvolved arm support, progressing to active motion as comfort dictates.
Scapular plane exercises (flexion and abduction), initially separate.
Stretching of anterior and posterior shoulder muscles (30s holds, 10s rest, 5-10 repetitions).

Strengthening Exercises

Focus on rotator cuff and scapular stabilizing muscles.
Exercises include TheraBand and weight-based exercises,
Scapula stabilizing exercises involve upper, middle, and lower trapezius, serratus anterior, anterior, middle deltoid, supraspinatus, infraspinatus, and teres minor strength training using exercises like chair press, push-up plus, and press-ups.

Chronic Tears, other factors, and classifications

Common in individuals >50 years with no prior shoulder trauma.
Characterized by intermittent shoulder pain.
Conservative rehabilitation may result in a successful outcome for chronic tears.
If the injuries are caused by acute injuries, surgical repair is required or considered.
Factors impacting successful rehabilitation include injury onset and location, associated pathologies (glenohumeral instability or fracture), preoperative strength and mobility, general health, patient age, approach type, repair type, patient mobility, and compliance.

Pain Management

Assess all shoulder joint areas, including cervical and thoracic spine segments, in addition to evaluating symptoms associated with the upper cross syndrome or scapular control.

Postoperative Management

Phase I: Immediate post-surgical phase.
Precautions include avoiding shoulder movements, lifting, and reaching behind the back.
Encourage continuous use of a shoulder splint.

Goals of management

Diminish pain and inflammation through cold therapy or electrical stimulation.
Preserve & protect the repair area integrity.
Maintain abduction orthosis or pillow position.
Maintain scapular plane and shoulder/elbow position
Duration of immobilization depends on tear size.

Preventing Mobility & Strength Loss and other issues

Maintain active ROM of the elbow, wrist, hand and cervical spine.
Pendulum exercises are implemented on the first postoperative day.
Removal of the immobilizer allows for exercise and passive ROM.
Maintain a supine position during initial phases to sustain scapular stability against the thorax.

Prevent or Correct Postural Deviations

Posture training and exercises are done to address and correct excessive thoracic kyphosis.
Low-intensity muscle-setting and isometric exercises in the healing period.
Exercises should be initiated as early as 1–3 weeks post-surgery, dependent on the extent of the tear and the quality of the repair.

Develop Control of Rotator Cuff and Scapulothoracic Stabilizers

Active movements of the scapula.
Submaximal isometrics of scapular muscles (side-lying).
Scapular isometric protraction, retraction, and elevation/depression.
Rotator cuff submaximal isometrics at the end of the phase

Phase II: Protection and Protected Active Motion

Precautions: no lifting (>5lb), no excessive behind-the-back movements, no sudden movements, and no body weight support on the hands.
Goals: allow soft tissue healing, continued progress towards full pain-free ROM, and decrease pain and inflammation.
Restore near-complete, non-painful, passive mobility.
Active assisted range of motion (ROM) for shoulder, initially in supine position with elbow flexed.

Phase III: Early Strengthening

Precautions: no lifting (>5lb), no sudden movements, and exercise should not be painful.
Continue with stretching, joint mobilization, and passive range of motion (PROM) exercises.
Increase shoulder strength, endurance, and dynamic stability.
Isometric and dynamic strengthening exercises focusing on the rotator cuff and other glenohumeral muscles.
Isotonic strengthening exercises tailored for pain-free ranges and light resistance.
Initiate light functional activities gradually.

Phase VI: Advanced Strengthening

Continue ROM exercises.
Continue progressive isotonic strengthening exercises.
Implement advanced proprioceptive and neuromuscular activities (PNF).

Proximal Biceps Tendonitis

Repeated use of the biceps, or problems in the shoulder area, can irritate the proximal biceps tendon.
Symptoms include pain in the shoulder and proximal biceps area.

Bicipital Tendonitis

More prevalent in overhead athletes, such as baseball pitchers, swimmers, and tennis players.
Direct injury or trauma to the tendon from excessive abduction or external rotations can lead to this condition.

Bicipital Tendonitis: Clinical Presentation

Athletes typically report pain with overhead activities or lifting weights.
Pain is usually located in the anterior part of the shoulder.
Pain typically manifests as an aching sensation exacerbated by overhead movements, pushing, or pulling.
Pain may diminish with rest.

Bicipital Tendonitis: Diagnosis

Physical examination reveals localized tenderness over the bicipital groove with pain during elbow flexion against resistance.
Diagnostic tests include speed test and Yergason test.

Bicipital Tendonitis: Treatment

Initially, treatment involves 3-4 weeks of NSAIDs for reducing inflammation and pain, supplemented by rest and ice.
Patients should avoid painful movements and activities like lifting or reaching.
Physical therapy is often recommended to achieve and maintain full and pain-free range of motion (ROM), bolster strength, and enhance endurance.

Return to Play

Athletes can usually return to play within approximately 3 weeks from treatment commencement, pending complete pain relief.

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Description

Explore the complexities of shoulder joint injuries and rotator cuff dysfunctions in this quiz. Learn about dynamic and static stabilizers, the anatomy of the rotator cuff, and factors leading to injuries. Perfect for students in sports science or physical therapy.