Shoulder Joint Anatomy & Injuries PDF

11/18/2023 Shoulder joint The glenohumeral joint  is one of the most frequently injured areas of the upper extremity in competitive sports Dynamic stabilizers:  Rotator cuff muscles  Scapular stabilizers  GH joint movers Static stabilizers:  Bon...

11/18/2023 Shoulder joint The glenohumeral joint  is one of the most frequently injured areas of the upper extremity in competitive sports Dynamic stabilizers:  Rotator cuff muscles  Scapular stabilizers  GH joint movers Static stabilizers:  Bony anatomy  Glenoid labrum  Capsular  Ligamentous 1  11/18/2023 Rotator cuff injuries Four muscles:  Supraspinatus  Infraspinatus  Teres minor  Subscapularis Function :  dynamic stability throughout ROM  Infraspinatus, teres minor, and subscapularis depress the humeral head Counteracting upward pull of the deltoid Infraspinatus and teres minor external rotators Subscapularis internal rotator 2  11/18/2023  Scapular dysfunction: improper positioning of the scapula in relation to the humerus ,Can lead to rotator cuff tears as the instability and impingement continue Factor of rotator cuff injury  Impingement syndromes  Répétitive microtrauma  Direct blows  Excessive tensile forces 3 11/18/2023 4  11/18/2023 Primary impingement Crowding of the subacromial space:  Hypertrophic degenerative changes of the AC joint  Thickening and calcifications of the coracoacromial ligament  Subacromial bursal thickening and fibrosis  Increased thoracic kyphosis  Structural variations in acromion  Trauma (direct macrotrauma or repetitive microtrauma) 5  11/18/2023 Secondary impingement  Usually as a result of GH or scapulothoracic instability  Instability at GH joint could be caused by: Excessive demand on capsule, Static stabilization attenuation ligaments and labrum Fatigued & tendon injury 2- Dynamic stabilization Anterior GH joint instability attenuation 6  11/18/2023 Internal impengment  90˚ abduction / 90˚ external rotation position  Rotator cuff tendons rotate posteriorly : ❖ Repeatedcontact between the tendons’ undersurface and posterior-superior glenoid rim ❖ Pinched or compressed between humeral head and rim 7  11/18/2023 Special test:  Neer test  Full/empty can tests (supraspinatus)  Drop arm test (rotator cuff tear)  Hawkins impingement test 8  11/18/2023 Stage I:Edema and hemorrhage ❖ Dull ach at the shoulder after activity may progress to occur during activity. ❖ Pain/tenderness over the greater tuberosity and anterior edge of the acromion process, with radiation down the lateral arm to the deltoid insertion. ❖ Rotator cuff pain does not radiate distal to the elbow ❖ Painful arc of active abduction (60˚ - 120˚) ❖ Pain-free passive ROM ❖ Strong but painful resisted abduction and/or external rotation ❖ Positive impingement and Neer tests ❖ Pain is minimal with use of the arm below breast level and is maximal between 90 and 120 degrees of active elevation/ abduction + horizontal adduction + with internal rotation maneuvers, such as scratching their back ❖ Lowering the arm from the overhead position is often more painful than raising it. ❖ Night pain ? could wake the patient up when rolling on the affected side (primary impingement) 9  11/18/2023 Stage II: Tendenitis and fibrosis ❖ limitation of active and passive ROM (capsular pattern) ❖ There may be a catching sensation with lowering of the arm caused by scar tissue entrapment beneath the acromion ❖ Soft tissue crepitus could be felt indicates thickening of the cuff during chronic conditions and scarring of the subacromial space Stage III: Bone spurs and tendon rapture  Visible atrophy of the supraspinatus and infraspinatus  Limitation in ROM more pronounced in active motion  Weakness of shoulder abduction and external rotation  - +ve drop arm test 10  11/18/2023 Early clinical stages: ❖ Aching only after activity ❖ Painful arc of active abduction (60˚ - 120˚) ❖ Pain-free passive ROM ❖ Clinician seldom sees patient at this point ❖ Education 1- Activity modification 2-Avoid impingement position in ADLs and training 3- Avoid poor posture ❖ Ice after workout 4- Ensure scapular dynamic stability 5- Emphasize maintaining correct posture while exercising 6- Regular planned evaluation of pain, muscle strength and ROM 11  11/18/2023 Later stages:  ROM and stretching exercises should be performed daily  Strengthening should be performed 3 times weekly 1- Modalities: Heat or cold (lack supporting research evidence, but are often utilized for pain management) Ultrasound or electrical stimulation (commonly applied but not supported by evidence) 2- Manual therapy Augment the effect of the exercise program 3- ROM exercises: - Begin with postural exercise such as shrugs and shoulder retraction - GH motion should begin with pendulum exercises 12  11/18/2023 Progress to active assisted motion  Cane, suspended pulleys or uninvolved arm  Then, active motion as comfort dictates (mirror)  Scapular plane in the early stages then flexion and abduction separately 4- Stretching exercises:  Should be performed daily and should include anterior & posterior shoulder muscles stretching (30s hold, 10s rest, 5-10 times) 13  11/18/2023  Pectoralis minor stretching is important for both primary and secondary impingement improve subacromial outlet  Cross-chest (horizontal adduction) and “sleeper” stretches have been shown to restore normal posterior GH joint mobility Strengthening exercises: ❖ Should focus on rotator cuff and scapula stabilizing muscles ❖ Rotator cuff – TheraBand - Weights 14  11/18/2023  Scapula stabilizing exercises: - Scaption upper, middle and lower trapezius, serratus anterior, anterior, posterior & middle deltoid, supraspinatus, infraspinatus, & teres minor  Chair press  Push-up plus  Press-ups  Rows  Closed kinetic chain flexion–extension. 15  11/18/2023  Nonoperative treatment is considered unsuccessful if the patient shows no improvement after 3 to 6 months of a comprehensive and coordinated medical and rehabilitative program.  After 6 months of appropriate conservative treatment, most patients have achieved maximal improvement from the nonoperative treatment program Classifications of rotator cuff tears ❖ Based on their timing - Acute - Chronic ❖ Based on underlying pathology - Traumatic - Degenerative ❖ Based on amount of tear - Partial-thickness - Full-thickness or complete tear 16  11/18/2023 Symptom: Neer’s classification stage II / III symptoms including: ❖ Pain at rest & at night - Particularly if lying on the affected shoulder Pain when lifting & lowering arm or with specific movements ❖ Weakness when lifting or rotating arm ❖ Crepitus or crackling sensation when moving shoulder in certain positions Adhesive capsulitis in chronic cases treatment ❖ Acute tears common in active patients surgical repair Advantage of early surgical repair: ❖ Better mobility of rotator cuff easier repair ❖ Good quality tendons more stable repair 17  11/18/2023 Chronic tears  common in people >50 years with no history of shoulder trauma  intermittent shoulder pain  conservative rehabilitation programme However, if conservative treatment fails or there was an acute tearing of a chronic injury surgical repair Factors that influence progression of rehabilitation after repair of rotator cuff :  Onset of injury  Size and location of the tear  Associated pathologies as GH instability or fracture  Preoperative strength and mobility of the shoulder  Patient general health  Age of patient  Type of approach  Type of repair  Mobility  Patient compliance with program 18  11/18/2023  Pain management  - ROM: Assess all joints in shoulder girdle + assess associated cervical & thoracic spine regions ? Upper cross syndrome  Evaluation of scapular control ? Scapulothoracic dyskinesis Upper cross syndrome 19  11/18/2023 Muscle strengthening: Time to start strengthening exercises depend on the diagnosis:  Simple impingement syndrome ? start day 1  Postoperative rotator cuff repair ? may require 10 weeks  strengthening should start by safe exercises such as isometrics and closed kinetic chain (CKC) exercises To strengthen internal or external rotation ?  Start with the arm at the side of the body and progress to 90 degrees of abduction. Postoperative management: Phase I: Immediate post surgical phase Precautions:  No AROM of the shoulder  No lifting of objects, reaching behind back, excessive stretching or sudden movements  No support of body weight on hands  Continuous use of splint 20  11/18/2023 Goals:  diminish pain & inflammation ( Cold therapy and electrical stimulation)  Maintain & protect repair integrity ? Immobilization  Abduction orthosis or pillow (shoulder elevated in the plane of the scapula approximately 45°, shoulder internally rotated, & elbow flexed) Duration of immobilization depend on the size of the tear Size of tear Sling use Active RoM Partial to small (5cm) 8 weeks 8 weeks 21  11/18/2023 Prevent loss of mobility and strength of peripheral joints:  Active ROM of the elbow, wrist & hand  Active ROM of the cervical spine  Could begin resisted isometrics/isotonic at the end of the phase for elbow, wrist and hand Prevent shoulder stiffness/restore shoulder mobility: Pendulum exercises ?  1st postoperative day  Immobilizer may be removed for exercise Passive ROM ?  Safe & pain-free ranges  Initially in supine position to maintain stability of the scapula on the thorax 22  11/18/2023 Prevent or correct postural deviations  Posture training and exercises to prevent excessive thoracic kyphosis Prevent inhibition & atrophy of GH musculature:  Low-intensity muscle-setting/isometric exercises (against minimal resistance)  Setting exercises should not provoke pain in a healing cuff tendon  Begin as early as 1 to 3 weeks postoperatively depending on the size of the tear and quality of the repair  Rhythmic stabilization exercises in balance position Develop control of rotator cuff and scapulothoracic stabilizers  Active movements of the scapula  Submaximal isometrics to isolated scapular muscles ? Side-lying  scapular isometric protraction/retraction and elevation/depression  Rotator cuff submaximal isometrics at the end of this phase 23  11/18/2023 Phase II: Protection and protected active motion phase Precautions:  No lifting of objects  No excessive behind back motions  No sudden movements  No support of body weight on hands Goals  Allow healing of soft tissue  Continuing to attain full or nearly full, pain-free ROM  Decrease pain and inflammation Restore nearly complete or full, non painful, passive mobility of the shoulder  Self-assisted ROM  Active assisted shoulder control (by therapist or family member)  active ROM Initially supine with the elbow flexed 24  11/18/2023 Phase III: Early strengthening precautions  No lifting objects >5lb (2.5 Kg)  No sudden lifting or pushing  Exercise should not be painful -Continue stretching, joint mobilization, PROM exercises as needed  - Increase strength & endurance & re-establish dynamic stability of the shoulder musculature  Isometric and dynamic strengthening  Submaximal multiple-angle isometrics of the rotator cuff and other GH musculature against gradually increasing resistance.  Isotonic strengthening & endurance training of the GH musculature within pain-free ranges against light resistance  Initiate light functional activities as tolerated 25  11/18/2023 Phase VI: Advanced strengthening phase  Continue ROM exercises  Continue progressive isotonic strengthening exercises  Advanced proprioceptive, neuromuscular activities 26 11/18/2023 27  11/18/2023 Special test  Speed test  Yergason test 28 11/18/2023 29