Shoulder

Shoulder

1. Labral Disorders

   • Bankart Lesion
     • anterior inferior (3-6 o'clock)
     • ant.-inf.
       • often caused by an anterior-inferior dislocation, resulting in anterior-inferior labral lesion (Bankart lesion)
       • 3-6 o'clock
   • Kim Lesion
     • post.-inf.
   • SLAP lesion
     • 10-2 o'clock
     • Snyder Classifications
       • type 1 - degeneration/fraying type 2 - affecting sup. labrum & biceps origin type 3 - bucket handle type 4 - bucket handle + proximal part of biceps origin
     • post-repair
       • first 6 weeks, PROM only; after that, AROM and submax isometrics ...if anterior: avoid ER, hor. ABD, and ext. past 0...if SLAP: avoid ER >30, long head stress (resisted elbow flexion & supination), combined elbow and shoulder extension
   • ages 34-55
   • higher demands
   • throwers
   • micro-trauma
     • often involving repetitive end-range ER (hence, throwers) <50% are from a macro-traumatic incident; and of those, it often is caused by a dislocation

2. Instability

   • "TUBS"
     • traumatic, unilateral, bankart lesion (anterior inferior), surgery unilateral instability is assoc. with labral tears (multidirectional MAY be assoc.)
   • "AMBRI"
     • atraumatic, multidirectional, bilateral, rehab usually effective, if surgery, anterior-inferior capsular shift
   • anterior
     • pain in 90-90, pain with end range extension, hor. ABD past 0; posterior cramping pain during these positions
   • posterior
     • pain with IR, flexion, hor. ADD
   • MDI
   • Special Tests
     • Load & Shift (graded 0/normal to 3/unstable), sulcus sign (inferior instability), apprehension & relocation test (anterior), posterior drawer (posterior), 
   • Treatment
     • anterior-inferior capsular shift; anterior/inferior capsule is folded over to strengthen/tighten in as a result, only PROM for first 6 weeks (avoid ER, hor. ABD, ext., 90-90); after that, submax isometrics - *avoid active IR b/c subscap inserts on labrum

3. GH Dislocations Complications

   • RTC tears
     • anterior (subscap) tears are assoc w/anterior dislocation posterior RTC tears (teres minor, infraspinatus) are assoc. w/posterior dislocation
   • Hill-Sachs lesion
     • occurs as a result of anterior dislocation followed by posterior-lateral impact 
   • Reverse Hill-Sachs lesion
     • occurs as a result of posterior dislocation, followed by anterior impact fracture
   • Bankart Lesion
     • assoc. with anterior-inferior dislocations
   • Dislocation Treatment
     • options:  -closed reduction -immobilization (run risk of frozen shoulder; elderly immobilized less time) - immobilize in 30 ER, physical therapy to address instability -surgery (capsular shift, thermal shrinkage)-treat as you would labral tear

4. Adhesive Capsulitis

   • limited AROM & PROM
     • so, NOT contractile tissue
   • Primary
     • unknown cause; just stiffness sets in subtly 
   • Secondary
     • known cause- ex. after being immobilized from a fracture/surgery, etc.
   • Stages
     • 1 - "freezing" - everything hurts! education is key! (pain does not equal harm) - highest level of kinesiophobia! 2 - "frozen" - they begin to tolerate stretching better, can increase treatment 3 - "thawing" - begin to see changes finally!
   • ages 40-65
   • female
   • risk factors
     • contralateral adhesive capsulitis, diabetes, thyroid disorder, depuytrens contracture, mastectomy

5. Post-Operative

   • acromion stress fractures
     • with reverse total shoulder arthroplastys (due to deltoid origin on acromion)
   • TSA precautions
     • avoid 90-90
   • Reverse-TSA precautions
     • avoid 90-90 & hand behind back (IR, ADD, Ext.)