Shoulder Joint and Rotator Cuff Injuries

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.

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.