Understanding Shoulder Joint Injuries

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.