Shoulder

Shoulder

1. Subacromial Impingement

   • impingement b/t GT and coracoacromial arch
   • Primary
     • decr. ROM
       • shoulder elevation and IR
     • PST
     • space-occupying lesion
       • often tendinosis or bursitis
     • 3 stages
       • 1. tendinitis & bursitis - inflammatory process, swelling & hemorrhage 2. tendinosis - repeated inflammatory process causes degenerative cascade, ligaments calcify, acromion undergoes morphogenesis  3. usually after 5th decade: osteophytes, bursal dessication, cysts
     • periacromial pain
     • painful arc
       • will last throughout range ; usually onset b/t 60 & 140
     • hypomobile
     • pec minor tight
     • pain w/IR
   • Secondary
     • hyperlaxity/instability
     • ROM WNL
       • except for possibly limited IR due to PST
     • PST
     • scapular dyskinesia
     • painful arc
       • may or may not last 'til end range; usually onset b/t 60 & 140 deg.
     • pain w/IR
     • muscle imbalance
   • Special Tests
     • Neer, Impingement Relief, Hawkins-Kennedy Clusters:  -SIS w/RTC: Hawkins-Kennedy, ER Weakness, Painful arc -SIS: Hawkins-Kennedy, ER weakness, Empty Can, Painful arc

2. Scapular Dyskinesia

   • decr. upward rot./incr. elevation
     • stronger upper trap than lower trap weak serratus anteriortight pec minorprotraction (tight rhomboids)
   • ant. tilt
     • tight pec minor weak lower trap
   • decr. ER
     • weak serratus anterior (winging)
   • Special Test
     • Scapular Assistance test (pushing scapula into posterior tilt, upward rotation; increases acromio-humeral distance by 1.7 to 2.1 mm

3. Interventions

   • eccentrics for tendinopathy
   • posture
   • ms imbalances
   • pec minor stretch
   • avoid positions
     • for primary: avoid repeated overhead motions for secondary: avoid end-range
   • SAD surgery
     • resect coracoacromial ligament and/or bursa, shave down acromion; focus on preventing kinesiophobia at first, gradually incr ROM and strengthening (progress as tolerated)

4. Internal Impingement

   • impingement b/t GT & post-sup aspect of glenoid
   • throwers, <40 y.o.
   • pain w/ABD + end range ER
     • pain w/flexion >120
   • could cause
     • RTC pathology, labral tear (probably b/t 10 &amp; 12 o clock)
   • posterior pain
   • 'typical tetrad'
     • hyperangulation (occurs during late cocking phase), scapular IR &amp; decr. upward rot., anterior hyperlaxity, PST (think of deceleration phase of pitching &amp; how it will change structures)
   • Special Tests
     • Posterior Impingement Test, Modified Apprehension Test&nbsp;

5. PST

   • in throwers, the posterior soft tissue structures undergo hypertrophy from undergoing large forces during deceleration
   • post. capsule
   • muscles
     • infraspinatus, teres minor, posterior deltoid
   • post. band of IGHL
   • sidelying inclinometry
     • normal: 83 deg. (measure when arm stops moving, you can no longer stabilize scapula or arm begins to ER)

6. Subcoracoid Impingement

   • impingement b/t LT and coracoid process
   • coracoid morphology
   • infraspinatus, subscap. tears
     • allowing humeral head to come forward
   • subscap. pathology
     • subscap. calcification, bursitis tendinopathy, cyst; can also result subscap. tendinopathy/tear
   • surgical reconstruction
     • to prevent anterior dislocation
   • ant. pain
     • may refer into biceps and proximal forearm
   • pain w/hor. ADD, flex, IR
   • assoc. impairments
     • subscap. tendinopathy/tear infraspinatus/teres minor&nbsp;weakness or tear,anterior hyperlaxity,PST ...all of these cause/allow anterior translation
   • Special Tests
     • Cross Arm test, Coracoid Impingement Test&nbsp;

7. RTC pathology

   • most common source of shoulder problems in the general population
   • Tendinopathy
   • Tears
     • by diameter - Di'Oreo &amp; Cofield classification (small, medium, large, massive) by depth - partial or full thickness
     • Risk Factors
       • age: in 4th decade, 100% chance of tendinosis (but may be asymptomatic), in 6th decade (65% chance of RTC tear) type 3 acromion coracohumeral interval stenosis-subscap.tear tendinosis causes degeneration, which incr. chance of tear macr-traumatic
       • Critical Angle
         • &gt;35 is a risk factor for a RTC tear (it basically measure how far the acromion extends laterally as compared to the glenoid)
       • Acromion Index
         • &gt; 0.70 increases risk of RTC tear due to impingement b/c glenoid should extend farther laterally than acromion --&gt; if acromion extends &gt;70% the distance that the glenoid extends
     • Cluster
       • RTC tear: Night pain, ER weakness, Age &gt;65
     • post-repair goals
       • prevent stiffness, prevent re-tears, restore function BE CONSERVATIVE (you'll get the same outcomes as if you would've been aggressive, and it's safer!) small vs. medium vs. large: PROM--&gt;AAROM--&gt;AROM &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;--&gt;strength
   • pain periacromial rgion
     • except for subscapularis&nbsp;
   • may refer to elbow
   • painful arc
   • pain lowering arm
     • 90 to 30 deg.
   • night pain

8. Long Head Bicipital Pain

   • often w/other patho.
   • tendinitis
   • tendinosis
   • subluxation
   • tear/rupture
   • MOIs
     • overuse, trauma, repetitive overhead movements, eccentric loading, subluxation in/out groove, anterior hyperlaxity,&nbsp;
   • popping/clicking
   • pain w/RIMT
   • pain w/stretch
   • pain w/palpate
   • pain w/throw
     • late cocking/follow through phase
   • Special Tests
     • Speed, Yergason&nbsp;
   • Surgery
     • Tenotomy - just cut the tendon; PROM only &nbsp;first 3 weeks; no resisted flexion/supination for 6 weeks tenodesis - relocate tendon farther down in bicipital groove - PROM only first 6 weeks; no resisted elbow flexion/supination for 10 weeks

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