Understanding Shoulder Joint Injuries

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Questions and Answers

Which muscles are part of the rotator cuff?

Biceps brachii

Teres major

Pectoralis major

Supraspinatus (correct)

What condition can lead to rotator cuff tears due to instability?

Tendinitis

Scapular dysfunction (correct)

Acute trauma

Frozen shoulder

Which of the following is not a type of impingement discussed?

Secondary impingement

Primary impingement

Tertiary impingement (correct)

Internal impingement

What is the primary function of the rotator cuff muscles?

To stabilize the GH joint throughout range of motion (D) Signup and view all the answers

Which special test is used to assess a rotator cuff tear?

Drop arm test (B) Signup and view all the answers

What is a common characteristic of rotator cuff pain?

Pain is maximal between 90 and 120 degrees of active elevation (D) Signup and view all the answers

Which symptom indicates Stage II rotator cuff conditions?

Limitation of active and passive range of motion (C) Signup and view all the answers

Which of the following is NOT recommended as part of early clinical stage education for rotator cuff conditions?

Perform routine strengthening exercises daily (D) Signup and view all the answers

What type of exercises are建议ed to be included in daily routines for patients with rotator cuff injuries?

Daily stretches of anterior and posterior shoulder muscles (C) Signup and view all the answers

Which assessment finding would be indicative of Stage III rotator cuff issues?

+ve drop arm test (C) Signup and view all the answers

What is the timeframe in which nonoperative treatment is considered unsuccessful?

3 to 6 months (C) Signup and view all the answers

What type of rotator cuff tear is common in people over 50 years with no history of shoulder trauma?

Chronic tears (A) Signup and view all the answers

Which stage of Neer's classification is associated with symptoms such as pain at rest and night?

Stage II / III (D) Signup and view all the answers

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

Better mobility of rotator cuff (C) Signup and view all the answers

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

Patient's favorite sports team (C) Signup and view all the answers

Which symptom might develop in chronic cases of rotator cuff issues?

Adhesive capsulitis (D) Signup and view all the answers

After how many months of conservative treatment do most patients achieve maximal improvement?

6 months (C) Signup and view all the answers

What type of tears are characterized by their size and amount of tissue affected?

Partial-thickness and full-thickness tears (A) Signup and view all the answers

What should be assessed in conjunction with the range of motion of the shoulder during evaluation?

Cervical & thoracic spine regions (B) Signup and view all the answers

Which of the following is a symptom when lifting or lowering the arm?

Weakness when lifting or rotating the arm (A) Signup and view all the answers

Signup and view all the answers

Study Notes

Shoulder Joint Injuries

The glenohumeral joint is a frequently injured area in competitive sports.
Dynamic stabilizers: Rotator cuff muscles, scapular stabilizers, and glenohumeral joint movers.
Static stabilizers: Bony anatomy, glenoid labrum, capsule, and ligaments.

Rotator Cuff Injuries

Four muscles: Supraspinatus, Infraspinatus, Teres minor, and Subscapularis.
Function: Dynamic stability throughout the range of motion (ROM).
Infraspinatus, teres minor, and subscapularis depress the humeral head, counteracting the upward pull of the deltoid.
Infraspinatus and teres minor are external rotators, and subscapularis is an internal rotator.

Scapular Dysfunction

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

Factors Contributing to Rotator Cuff Injuries

Impingement syndromes
Repetitive microtrauma
Direct blows
Excessive tensile forces

Impingement Syndrome

Intrinsic causes: Acromion derangement causing supraspinatus tendon damage and irritation.
Extrinsic causes:
- Primary: Chronic overhead movements (baseball, volleyball, etc.).
- Secondary: Muscular imbalance (common in throwing athletes, especially those performing overhead presses).

Clinical Presentation

Pain in the anterior superior lateral shoulder area.
Pain with shoulder abduction and other overhead movements.
Associated sleep disturbance due to point tenderness in the anterior-lateral aspect of the shoulder.
Gradual onset, often linked to increased training/activity or changes in athletic gear.

Primary Impingement

Crowding of the subacromial space
Hypertrophic degenerative changes in the acromioclavicular (AC) joint
Thickening and calcification of the coracoacromial ligament
Subacromial bursal thickening and fibrosis
Increased thoracic kyphosis
Structural variations in the acromion
Trauma (direct or repetitive).

Secondary Impingement

Usually a result of glenohumeral or scapulothoracic instability.
Instability at the GH joint can be caused by:
- Excessive demand on capsule, ligaments, and labrum.
- Fatigued and tendon injury
- Anterior GH joint instability

Internal Impingement

90° abduction and 90° external rotation position.
Rotator cuff tendons rotate posteriorly.
Repeated contact between tendons' undersurface and posterior-superior glenoid rim
Pinched or compressed between humeral head and rim.

Diagnosis

Clinical examination.
Range of motion (ROM) testing often reveals a painful arc between 45° to 120° of abduction.
Manual strength testing may show pain-related weakness, especially with abduction and internal/external rotation.

Special Tests

Neer test
Full/empty can tests (supraspinatus)
Drop arm test (rotator cuff tear assessment)
Hawkins impingement test

Neer's Classification of Shoulder Impingement

Stage I: Edema, hemorrhage (typically in patients under 25).
Stage II: Tendinitis/bursitis, and fibrosis (typically in patients aged 25-40).
Stage III: Bone spurs and tendon rupture (typically in patients over 40).

Stage I: Edema and Hemorrhage

Symptoms include dull ache after activity that may progress to during activity, pain/tenderness over greater tuberosity and anterior edge of acromion, pain radiating to deltoid insertion, painful arc of active abduction (60-120°), strong, but painful resisted abduction/external rotation, and positive impingement and Neer tests.
Pain minimal with arm below breast level. Maximal pain between 90-120° active elevation/abduction and internal rotation, and is often more painful lowering than raising.
Pain often at night, especially when rolling onto the affected side (primary impingement).

Stage II: Tendinitis and Fibrosis

Limitation in active and passive ROM (capsular pattern).
Potential catching sensation, scar tissue entrapment beneath acromion, and soft-tissue crepitus (indicates thickening of the cuff).

Stage III: Bone Spurs and Tendon Rupture

Visible atrophy of supraspinatus and infraspinatus.
More limited ROM, particularly in active motion.
Weakness in shoulder abduction and external rotation. Positive drop arm test

Early Clinical Stages

Aching only after activity.
Painful arc of active abduction (60°–120°).
Pain-free passive ROM.

Education/Treatment

Activity modification.
Avoiding impingement positions during ADLs and training.
Improving posture.
Ice after workouts.
Maintaining scapular dynamic stability.
Practicing proper posture during exercise.
Routine evaluations of pain, muscle strength, and ROM.

Later Stages

ROM and stretching exercises (daily).
Strengthening exercises (3 times weekly).
Modalities (heat or cold).
Manual therapy.
ROM exercises.

Progressing to Active Assisted Motion

Cane, suspended pulleys, or uninvolved arm.
Scapular plane in early stages; then flexion and abduction separately.
Stretching exercises (daily), include anterior and posterior shoulder muscles (30-second hold, 10-second rest).

Strengthening Exercises

Focus on rotator cuff and scapular stabilizing muscles.
Rotator cuff exercises: TheraBand and weights (various exercises).
Scapular stabilizing exercises: Scaption, chair press, push-ups plus, press-ups, rows.

Chronic Tears

Common in people over age 50 with no history of shoulder trauma, intermittent pain.
Conservative rehabilitation fails or acute tearing of a chronic injury requiring surgical repair.
Factors that influence progression of rehabilitation after repair:
- Onset of injury
- Size and location of tear
- Associated pathology
- Preoperative shoulder mobility
- Patient's general health
- Age
- Type of approach
- Type of repair
- Mobility
- Patient compliance with the program

Pain Management

ROM assessment of all shoulder girdle joints and associated cervical and thoracic spine regions.
Evaluation of scapular control and scapulothoracic dyskinesia.

Upper Cross Syndrome

Tight upper trapezius, levator scapulae, and pectoralis muscles.
Weak lower trapezius and serratus anterior.

Muscle Strengthening (Post-operative)

Time to start strengthening varies based on the type of diagnosis .
Strengthening begins with isometric and closed-kinetic chain exercises.
Progression to internal/external rotation, then to 90 degrees of abduction.

Postoperative Management (Phase I)

Precautions: No active ROM (AROM) of shoulder, no weight-bearing on hands or lifting, no excessive stretching or sudden movements.
Continuous use of sling or splint.

Goals

Diminish pain and inflammation (e.g., cold therapy, electrical stimulation).
Maintaining repair integrity.
Achieving/maintaining full and pain-free ROM.
Increasing strength and endurance.

Duration of Immobilization

Duration varies based on the size of the tear:
- Partial/small tears: 4 weeks (sling use and active ROM)
- Medium/large tears: 6 weeks (sling use and active ROM)
- Massive tears: 8 weeks (sling use and active ROM)

Preventing Loss of Mobility/Strength of Peripheral Joints

Active ROM of elbow, wrist, hand, and cervical spine.
Resisted isometrics/isometrics can be started later in the rehabilitation phase.

Preventing Shoulder Stiffness/Restoring Shoulder Mobility

Pendulum exercises (first postoperative day, after immobilizer removed).
Passive ROM.
Supine position to maintain scapular stability.

Preventing/Correcting Postural Deviations & Inhibiting GH Atrophy

Posture training & exercises.
Low-intensity muscle setting/isometric exercises
Early initiation, based on the size of the tear and quality of repair.
Rhythmic stabilization exercises (in balance position).

Developing Control of Rotator Cuff/Scapulothoracic Stabilizers

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

Phase II: Protection & Protected Active Motion

Precautions: No lifting of objects over 5 pounds, avoid excessive behind-the-back motions, no sudden movements, no supporting body weight on hands
Goals: Allow soft tissue healing, continue progress towards full pain-free range of motion (ROM), decrease pain and inflammation.
Restore nearly complete or full passive mobility. Self-assisted ROM, active assisted shoulder control by therapist or family. Active ROM, initially supine with elbow flexed.

Phase III: Early Strengthening

Precautions: No lifting > 5 lbs., no sudden lifting or pushing, exercises should not be painful
Isometric and dynamic strengthening (submaximal multiple-angle isometrics of rotator cuff and other GH muscles, isotonic strengthening & endurance training within pain-free ranges).
Initiate light functional activities as tolerated.

Phase VI: Advanced Strengthening Phase

Continue ROM and progressive isotonic strengthening exercises.
Advanced proprioceptive, neuromuscular activities (e.g., exercises).

Proximal Biceps Tendonitis (Tendinitis)

Repeated use of biceps or shoulder problems.
Irritation of proximal biceps tendon.
Pain in shoulder and biceps.

Bicipital Tendonitis

Overhead athletes (baseball pitchers, swimmers, and tennis players).
Pain/tenderness over biceps groove.
Pain worsens with flexion against resistance

Diagnosis (Bicipital Tendonitis)

Physical exam reveals tenderness over bicipital groove.
Pain with elbow flexion against resistance.
Special tests: Speed test and Yergason test.

Treatment (Bicipital Tendonitis)

Initial treatment: NSAIDs, rest, ice, avoid painful movements (e.g., reaching, lifting).
Physical therapy: ROM, increasing strength/endurance, achieving/maintaining full and painless ROM.

Return to Play

Approximately 3 weeks, or when pain has resolved completely.

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Description

This quiz covers key concepts related to shoulder joint injuries, focusing on the glenohumeral joint, rotator cuff injuries, and scapular dysfunction. It also discusses contributing factors to these injuries, including impingement syndromes and repetitive microtrauma. Test your knowledge on the anatomy and mechanics of shoulder stabilization.