Orthopedic Management of the Shoulder Chapter 22 p. 392

Anatomy Review (GH joint) Glenohumeral Joint Bones Scapula Glenoid fossa Acromion process Scapular spine Axillary border Vertebral border Humerus Humeral head Surgical neck Anatomic neck Greater tubercle Lesser tubercle Intertubecular (bicepital groove) Muscles Deltoid Anterior Middle Posterior Rotator Cuff S.upraspinatus I.nfraspinatus T.eres Minor S.ubscapularis Biceps Triceps Pectoralis Major Latissimus Dorsi Teres Major Actions of these muscles?

Anatomy Review (GH Joint cont) Bursa Subacromial Labrum Function? Ligaments (Capsule) Superior Glenohumeral ligament Middle Glenohumeral ligament Inferior Glenohumeral ligament Redundant folds Coracohumeral ligament Coracoacromial ligament Provide Anterior Support Provide Superior Support

Anatomy Review (GH joint cont.) Motions? Planes? Axis? Degrees of Freedom? ROM estimates?

Anatomy Review (AC joint) Acromioclavicular Joint Bones Scapula Acromion process Clavicle Ligaments AC ligament Coracoacromial Ligament Bifurcated Conoid Trapezoid Motions? Planes Axis? Degrees of Freedom?

Anatomy Review (SC Joint) Sternoclavicular Joint Bones Sternum Clavicle Ligaments Interclavicular ligament Sternoclavicular ligament (2) Anterior Posterior Motions? Planes? Axis? Degrees of Freedom?

Anatomy Review (ScapuloThoracic Junction) Bones? Muscles? Movements? Scapulohumeral Rhythm? Implications?

Common Pathologies Glenohumeral Joint Acromioclavicular Joint Impingement syndrome Rotator cuff tear Adhesive capsulitis Dislocation Subluxation Bankart Lesion SLAP lesion Hill-Sachs lesion Multidirectional Instability (MDI) Acromioclavicular Joint Separation

Impingement Syndrome Very common Cause Laborers Athletes Persons who do repetitive overhead motion Cause “the tendons of the rotator cuff (and subacromial bursa) are crowded, buttressed, or compressed under the coracromial arch, resulting in mechanical wear, stress, and friction” fig. 22-1 p. 393

2 types of Impingement Primary Secondary Mechanical compression of r/c tendons Primarily which one? Secondary Related to GH instability that creates reduced subacromial space Causes of GH instability?

Subacromial Space Causes for decreased subacromial space Degenerative changes Osteophyte formation On Acromion process Shape of acromion process Straight Slight hook Hooked Loss of scapular stabilization

Supraspinatus tendon Most common structure involved with impingement Hypovascular just proximal to insertion point on humerus “watershed zone” “critical zone” How damaged Overhead activities Mechanical wear Stress Friction Can lead to Impingement Tendonitis Tears

Stages of Rotator Cuff Impingement Related to age and degenerative changes Stage I Younger patients <25 y/o (can occur at any age) Clinical features Edema Hemorrhage Pain worse with >90 degrees abd. Reversible lesion Stage II Middle age patients 25-40 y/o Pain with ADL’s PM pain Fibrotic changes of Supraspinatus tendon Biceps tendon Subacromial bursa Irreversible because of long term repeated stress

Stages of Rotator Cuff Impingement Stage III >40 y/o Long history of repeated shoulder pain and dysfunction Characterized by Tendon degeneration R/C tears R/C ruptures Significant muscle weakness/atrophy

Rehabilitation of Primary and Secondary Rotator Cuff Impingement Scapular Weakness Affects humeral head stabilization “functional scapular instability” Affects Scapular position during activities that causes “relative decrease in subacromial space” This can cause secondary impingement Weak scapular muscles (serratus anterior, traps (3), levator scapula, rhomboid) p. 394 2nd paragraph

Rehabilitation of Primary and Secondary Rotator Cuff Impingement Rehabilitation Program Phase I Pain/inflammation control Modification of activities Stretching Phase II (recovery stage) Criteria for moving to phase II Improved motion without pain ADL’s without pain Scapular strengthening R/C strengthening Phase III (functional recovery) Move slowly/cautiously Overhead activities incrementally

Surgical Management of Shoulder Impingement When used PT fails R/C tears Neer’s stage III impingement Tendon degeneration Cuff tears Management with no cuff tear Subacromial decompression Rehab Same as before surgery

Surgical Management of Shoulder Impingement Management with rotator cuff tear 3 types of cuff tear Type I <1cm Type II 1-3cm Type III >5cm

Type I R/C Tear Rehabilitation Active motion and pain-free exercise can begin as soon as patient tolerates Same as before surgery

Type II/III Rehabilitation Tissue protection must be longer to allow for soft-tissue healing “rehabilitation must match surgical procedure” Wilk and Mangine Open procedure-anterior deltoid resection Open procedure-lateral deltoid splitting Arthroscopic Larger cuff repairs take longer to heal

Rehab after decompression Same as before decompression 3 phases Phase I (early recovery) (acute stage) (maximal protective phase) Approx 6 weeks Pain/inflammation control Protected motion (if applicable) Type I cuff tears and less Submaximal isometrics as soon as pain allows Abductors, ER, IR, flexors, elbow flexors, gripping PROM AAROM Performed pain free ROM and strength gradually increase as pain decreases

Rehab after decompression Phase II (intermediate) (fibroblastic phase) (moderate protective phase) 7-12 weeks No flexion >90 degrees Increase strength Concentrics/eccentrics Humeral head stabilization exercises (scapular stabilization) Maintenance of pain control Avoid repetitive motions

Rehab after decompression Phase III (maturation) (tissue remodeling) (minimum protection phase) Weeks 13-21 Begins when patient shows increased motion without symptoms Gradual return to normal activites