Derbyshire Sports Injuries Clinic presents The Shoulder

Shoulder anatomy-bones

Shoulder anatomy-ligaments

Shoulder anatomy-muscles

Shoulder anatomy-bursae

The gleno-humeral joint Ball & 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 Labrum deepens the socket by 75% and widens it by 50%

Other joints involved in shoulder movement Acromio-clavicular Scapulo-thoracic Sterno-clavicular The 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

Causes of shoulder pain Rotator cuff musculature Instability Stiffness AC joint Referred pain

Rotator cuff Acute, chronic or acute on chronic Acute: muscle strains, partial or complete tendon tears RC tendon injuries frequently present as impingement

Instability Pain 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

AC Joint Often mistaken for shoulder pain Is actually very specific pain and symptoms are localised on questioning

Shoulder stiffness Can be from: Trauma Post-surgical Injury to the cervical nerve roots and/or brachial plexus Spontaneously for no reason... Adhesive capsulitis

Referred pain Very common referral site from the cervical spine, upper thoracic spine and associated soft tissue: Levator scapulae Trapezius Rotator cuff muscles Tumours Axillary vein thrombosis Perforated duodenal ulcer

Patient walks in c/o shoulder pain Where 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 difficulties Popping in/ out? Night pain is common in impingement and RC issues but other red flags should be screened for

Clinical pearls In 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 joint Fall on outstretched arm: SLAP or Bankhart tear In chronic injuries the position that hurts during activity is important to ascertain

Assessment of the shoulder Active + passive movements: Flexion External rotation: arms by side and 90° abduction Internal rotation Horizontal flexion Resisted movements: External rotation Subscapularis lift off test Deltoid Supraspinatus- ‘Empty can test’-scaption & internal rotation Biceps- ‘Speed’s test- supination through range

Special tests AC joint Impingement: Instability: Compression ‘Scarf test’: horizontal flexion Impingement: Neer’s: Full flexion EOR Hawkin’s and Kennedy’s: flex to 90° and internally rotate Instability: Load and shift test: sitting, distract and move anteriorly and posteriorly Aprehension 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

Impingement The 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

Diagnoses associated with rotator cuff impingement Subacromial bone spurs and/ or bursal hypertrophy AC joint arthrosis and/ or bone spurs Rotator cuff disease Superior labral injury Glenohumeral internal rotation deficit (GIRD) Glenohumeral instability Biceps tendinopathy Scapular dyskinesis Cervical radiculopathy

Types of impingement Primary 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 impingement Impingement of the RC occurs against the posterior-superior surface of the glenoid, eventually causes damage to the labrum

Rotator cuff injuries Common Rotator cuff tendon becomes swollen Pain with overhead activities Often associated instability... Symptoms of recurrent subluxations and ‘dead arms’ Painful arc between 70°-120° MRI is assessment tool of choice Patients respond well to physiotherapy: must correct the imbalances causing the injury One 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

Glenoid Labrum tears Superior aspect of the glenoid labrum is the attachment site for the tendon of the long head of biceps (LHB) Injuries to the labrum are SLAP: 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.

SLAP tears Repetitive throwing overhead Fall on outstretched arm Pain is poorly localized, worse with overhead activities Popping, grinding, catching are often present Biceps is often tender on palpation and on testing MR arthrography is the test of choice All unstable labral tears require surgery

Dislocation of the GH joint Anterior dislocation due to excessive abduction/ external rotation Most result in a bony Bankart lesion or a Hill-Sach’s lesion (fracture of the humeral head posteriorly) Acute trauma is always the cause Most have a sensation of ‘popping out’ Dislocated shoulders should be X-rayed prior to reduction if possible as a fracture can be present The arm should not be put in a sling, but needs resting at night in external rotation Surgical results are good with only 10% re-dislocation, whereas non-surgical patients have very high re-dislocation rates

Shoulder instability Common in people with general laxity Anterior instability: mainly post-traumatic but can also be with capsular laxity Pain is usually due to RC tendon impingement X-ray should be done to exclude any fracture associated with instability. Posterior instability is normally associated with multidirectional instability

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.

Clavicle fractures Most 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 superiorly Very painful! Localized tenderness Swelling Bony deformity Principle 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

AC joint injuries Usually results from a fall onto the point of the shoulder Grading system of injuries is I-VI Surgery 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

Chronic AC joint pain Repeated 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 osteoporosis Physio, corticosteroid injections and in some cases surgery is needed.

Referred pain Cx and Tx spine refer to the shoulder Also, 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 shoulder Adverse neural tension/ restricted neural dynamics can have a major part to play in shoulder pain

Don’t miss Ruptured LHB Pec Major tear Nerve 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!

Books to stand you in good stead Clinical Sports Medicine 4th edition: Brukner & Khan Orthopaedic Physical Assessment 5th edition: David J Magee