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Derbyshire Sports Injuries Clinic presents The Shoulder

The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

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Page 1: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Derbyshire Sports Injuries Clinic presents

The Shoulder

Page 2: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder anatomy-bones

Page 3: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder anatomy-ligaments

Page 4: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder anatomy-muscles

Page 5: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder anatomy-bursae

Page 6: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

The gleno-humeral jointBall & socket joint which is inherently unstable

due to a shallow socket. Additional stability is provided by:

Static:GH ligaments, labrum & capsule and Dynamic constraints: rotator cuff & scapula

stabilising. The RC muscles act as humeral depressors and centre the humerus in the joint. They work in opposition the deltoid and prevent the humerus rising up and impinging on the undersurface of the acromion

Page 7: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Other joints involved in shoulder movementAcromio-clavicularScapulo-thoracicSterno-clavicularThe smooth movement of all of the joints

together is called ‘Scapulo-humeral rhythm’.Upward rotation of the scapula ensures the

coracoacromial arch is removed from the path of the upwardly elevating humerus

This also enhances stability at >90° by placing the glenoid fossa under the humeral head

Page 8: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Causes of shoulder pain1. Rotator cuff

musculature2. Instability3. Stiffness4. AC joint5. Referred pain

Page 9: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Rotator cuffAcute, chronic or

acute on chronicAcute: muscle

strains, partial or complete tendon tears

RC tendon injuries frequently present as impingement

Page 10: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

InstabilityPain from instability can arise from the

anterior, posterior or superior shoulder capsule and labrum.

Glenoid labral lesions may occur either acutely or as a repetitive injury

Can be observed in people who have recurrent episodes of dislocation or subluxation

Initially instability causes symptoms like impingement or joint pain

Page 11: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

AC JointOften mistaken for shoulder painIs actually very specific pain and symptoms

are localised on questioning

Page 12: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder stiffnessCan be from:

TraumaPost-surgicalInjury to the cervical nerve roots

and/or brachial plexusSpontaneously for no reason...

Adhesive capsulitis

Page 13: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Referred painVery common referral

site from the cervical spine, upper thoracic spine and associated soft tissue:Levator scapulaeTrapeziusRotator cuff muscles

TumoursAxillary vein thrombosisPerforated duodenal

ulcer

Page 14: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Patient walks in c/o shoulder painWhere is the pain?How long have you had the pain?Is there a mechanism of injury?Sport?Work activity?Any neck pain, headaches, pins and needles,

numbness, breathing difficultiesPopping in/ out?Night pain is common in impingement and RC

issues but other red flags should be screened for

Page 15: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Clinical pearlsIn acute injuries the position of the shoulder

when injury takes place is important:Arm wrenched backwards in a vulnerable

position: suspect anterior dislocation or subluxation

Fall onto the point of the shoulder: AC jointFall on outstretched arm: SLAP or Bankhart tear

In chronic injuries the position that hurts during activity is important to ascertain

Page 16: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Assessment of the shoulderActive + passive movements:

FlexionExternal rotation: arms by side and 90° abductionInternal rotationHorizontal flexion

Resisted movements:External rotationSubscapularis lift off testDeltoidSupraspinatus- ‘Empty can test’-scaption & internal

rotationBiceps- ‘Speed’s test- supination through range

Page 17: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Special testsAC joint

Compression ‘Scarf test’: horizontal flexion

Impingement:Neer’s: Full flexion EORHawkin’s and Kennedy’s: flex to 90° and internally rotate

Instability:Load and shift test: sitting, distract and move anteriorly

and posteriorlyAprehension test: supine abduct and externally rotate

shoulder, posterior translation of the shoulder relieves dislocation apprehension, anterior translation exacerbates it

SLAP test: O’Brien’s test- pronation resisted

Page 18: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

ImpingementThe theory is that the

impingement occurs when the rotator cuff tendons are impinged as they pass through the subacromial space

(the space formed between the acromion, coracoacromial arch and AC joint and the glenohumeral joint below)

The impingement causes mechanical irritation of the rotator cuff tendons and may result in swelling and damage to the tendons

Page 19: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Diagnoses associated with rotator cuff impingementSubacromial bone spurs and/ or bursal

hypertrophyAC joint arthrosis and/ or bone spursRotator cuff diseaseSuperior labral injuryGlenohumeral internal rotation deficit (GIRD)Glenohumeral instabilityBiceps tendinopathyScapular dyskinesisCervical radiculopathy

Page 20: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Types of impingementPrimary external impingement:

Encroachment of the space due to acromion shape, either congenital or due to spurs

Secondary external impingement:Due to inadequate muscular stabilisation of the

scapula or weakness of the rotator cuff muscles creating a muscle imbalance

Internal impingementImpingement of the RC occurs against the

posterior-superior surface of the glenoid, eventually causes damage to the labrum

Page 21: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Rotator cuff injuries CommonRotator cuff tendon becomes swollenPain with overhead activitiesOften associated instability... Symptoms of recurrent

subluxations and ‘dead arms’Painful arc between 70°-120°MRI is assessment tool of choicePatients respond well to physiotherapy: must correct the

imbalances causing the injuryOne single corticosteroid subacromial injection also

shows good evidence of efficacy if in conjunction with rehabilitation

Calcific tendinopathy can occur (idiopathic), seen on X-ray/ ultrasound

Page 22: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Glenoid Labrum tearsSuperior aspect of the glenoid labrum is

the attachment site for the tendon of the long head of biceps (LHB)

Injuries to the labrum areSLAP: extend from anterior to the biceps

tendon to posterior to the tendon. There are 4 types of SLAP lesions.

SLAP tears are stable or unstable depending on how much of the biceps tendon is attached to the glenoid margin

Non-SLAP lesions include degenerative, flap, vertical labral tears and unstable Bankart lesions.

Page 23: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

SLAP tearsRepetitive throwing overheadFall on outstretched armPain is poorly localized, worse with overhead

activitiesPopping, grinding, catching are often presentBiceps is often tender on palpation and on

testingMR arthrography is the test of choiceAll unstable labral tears require surgery

Page 24: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Dislocation of the GH jointAnterior dislocation due to excessive abduction/

external rotationMost result in a bony Bankart lesion or a Hill-

Sach’s lesion (fracture of the humeral head posteriorly)

Acute trauma is always the causeMost have a sensation of ‘popping out’Dislocated shoulders should be X-rayed prior to

reduction if possible as a fracture can be presentThe arm should not be put in a sling, but needs

resting at night in external rotationSurgical results are good with only 10% re-

dislocation, whereas non-surgical patients have very high re-dislocation rates

Page 25: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Shoulder instabilityCommon in people with general laxityAnterior instability: mainly post-traumatic but

can also be with capsular laxityPain is usually due to RC tendon impingementX-ray should be done to exclude any fracture

associated with instability. Posterior instability is normally associated

with multidirectional instability

Page 26: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Adhesive Capsulitis Usually between 40-60 years of age More commonly the left?? More prevalent in women More common in diabetics, thyroid disorders and users of

matrix degradation inhibitors Shoulder becomes stiff in the ‘capsular pattern’ of limitation of

abduction < external rotation <internal rotation Post-surgical stiffness usually resolves in a year Idiopathic Adhesive capsulitis normally resolves within 2.5 years Surgical interventions are not very successful, steroid injections

give some patients relief (particularly if done under X-ray, into the joint), physiotherapy helps some patients, and although range of movement is temporarily restored, an MUA often has a poor outcome.

Page 27: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Clavicle fracturesMost common fracture seen in sport... Usually a fall onto the

point of the shoulder or direct contact.Usually fractures in its middle 1/3rd with the outer fragment

displacing inferiorly and the medial fragment superiorlyVery painful!Localized tendernessSwellingBony deformityPrinciple treatment is pain relief, figure of 8 bandage can be

used. During the first 4-6 weeks shoulder flexion is restricted to 90°

Distal clavicular fractures must be referred for an orthopaedic consult for assessment and management

Page 28: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

AC joint injuriesUsually results from a fall onto

the point of the shoulderGrading system of injuries is I-

VISurgery is suggested for

Grade IV-IV and Grade III’s that fail conservative treatment (Grade III onwards presents with increasing amount of deformity and should be referred for an orthopaedic consult.

AC joint injuries are easy to diagnose with a diagnostic LA

Page 29: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Chronic AC joint painRepeated minor injuries to the joint after a

previous AC injury which aggravates the already damaged meniscus of the AC joint

Osteolysis can be seen at the edge of the AC joint

X-ray shows marked osteoporosisPhysio, corticosteroid injections and in some cases surgery is needed.

Page 30: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Referred painCx and Tx spine refer to the shoulderAlso, a sore shoulder can refer to the scapula and

upper trapezius area.Trigger points in the neck and scapula muscles

have active referral areas to the shoulderAdverse neural tension/ restricted neural

dynamics can have a major part to play in shoulder pain

Page 31: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Don’t missRuptured LHBPec Major tearNerve entrapments:

Suprascapular nerve: C5,6- wasting of infraspinatus, supraspinatus, vague deep ache

Long thoracic nerve palsy: C5,6,7- serratus anterior palsy. This is the backpack injury!

Page 32: The Shoulder. Shoulder anatomy-bones Shoulder anatomy-ligaments

Books to stand you in good steadClinical Sports

Medicine 4th edition: Brukner & Khan

Orthopaedic Physical Assessment 5th edition: David J Magee