shoulder exam and instability - fisiokinesiterapia · chief complaint pain at night; can’t sleep...

Shoulder Exam and Shoulder Exam and InstabilityInstability

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HistoryHistory

DurationDuration–– <2wks => dislocation, fracture, RCT<2wks => dislocation, fracture, RCT–– >2wks => chronic symptoms; m/c>2wks => chronic symptoms; m/c

Mechanism of injuryMechanism of injury–– Football player w/ fall onto shoulder; pain Football player w/ fall onto shoulder; pain

and deformity at AC jointand deformity at AC joint

Age and chief complaintAge and chief complaint

Chief ComplaintChief Complaint

Pain at night; canPain at night; can’’t sleep on shouldert sleep on shoulder–– Rotator cuff tearRotator cuff tear

Pain localized to top of shoulderPain localized to top of shoulder–– Arthritis, AC joint separationArthritis, AC joint separation

Pain in deltoid region; radiates down lateral Pain in deltoid region; radiates down lateral arm arm –– BursitisBursitis

Tingling sensation; aggravated by lifting armTingling sensation; aggravated by lifting arm–– Rotator cuff tearRotator cuff tear

Shoulder slips out of jointShoulder slips out of joint–– instabilityinstability

Patient AgePatient Age

Young patientYoung patient–– Instability, AC joint separation, dislocationInstability, AC joint separation, dislocation

MiddleMiddle--aged patientaged patient–– Impingement syndrome, RCT, adhesive Impingement syndrome, RCT, adhesive

capsulitiscapsulitis (female) (female) Older patientOlder patient–– RCT, degenerative arthritis, adhesive RCT, degenerative arthritis, adhesive

capsulitiscapsulitis

NeerNeer Impingement SignImpingement Sign

Patient seatedPatient seatedForcibly flex arm to Forcibly flex arm to overhead positionoverhead positionPain => Pain => humerushumerusimpinges against CA impinges against CA archarch

AcromioclavicularAcromioclavicular jointjoint

Palpate Palpate posterior posterior marginmargin of AC jointof AC jointExaggerated w/ cross Exaggerated w/ cross arm adductionarm adduction

SubacromialSubacromial bursabursa

Palpate from Palpate from anteroantero--lateral lateral acromionacromiondown down deltioddeltiodAcromiohumeralAcromiohumeralsulcussulcusPain => bursitis , Pain => bursitis , RCTRCT

Internal shoulder rotationInternal shoulder rotation

Patient seatedPatient seatedPlace dorsum of Place dorsum of hand against backhand against backNote vertebra pt Note vertebra pt reachesreaches

SupraspinatusSupraspinatus strength teststrength test

90 deg abduction90 deg abduction30 deg forward 30 deg forward flexionflexionThumbs downThumbs downPush down as patient Push down as patient resistsresistsPain => RCTPain => RCT

Inferior instabilityInferior instability

Arm abducted 90 degArm abducted 90 degApply direct Apply direct pressure downward pressure downward to to midhumerusmidhumerus

Posterior instabilityPosterior instability

Shoulder flexion 90 Shoulder flexion 90 degdegPush posteriorPush posterior

HawkinHawkin’’ss impingement signimpingement sign

Throwing positionThrowing positionFlex forward 30 degFlex forward 30 degForcibly int. rotateForcibly int. rotatePain => impingement Pain => impingement of of supraspinatoussupraspinatousagainst CA ligamentagainst CA ligament

External rotationExternal rotation

Patient seatedPatient seatedext rotate both armsext rotate both arms

Restricted => Restricted => adhesive adhesive capsulitiscapsulitis

Crossed arm adductionCrossed arm adduction

Arm across chest as Arm across chest as far as comfortably far as comfortably possiblepossibleRestricted => tight Restricted => tight posterior capsuleposterior capsuleAC joint painAC joint pain

Apprehension signApprehension sign

Throwing positionThrowing positionPull into ext rotation Pull into ext rotation and extensionand extensionPt will drop arm to Pt will drop arm to avoid avoid subluxationsubluxation or or dislocationdislocation

SulcusSulcus signsign

Arm at sideArm at sidePull inferiorlyPull inferiorlyDeepening of Deepening of acromiohumeralacromiohumeralsulcussulcus => inferior => inferior GH instabilityGH instability

Abduction Abduction –– coronal planecoronal plane

Extend shoulder Extend shoulder posteriorlyposteriorlyAbduct shoulderAbduct shoulderPain => impingement Pain => impingement of greater of greater tuberositytuberosityagainst lateral against lateral acromionacromion

Shoulder InstabilityShoulder Instability

Shoulder InstabilityShoulder Instability-- AAnatomynatomy

GlenoidGlenoid LabrumLabrum–– adds 50% depth to adds 50% depth to

glenoidglenoid; passive ; passive stabilitystability

–– ant labrum acts as ant labrum acts as attachment for attachment for middle and sup. middle and sup. glenohumeralglenohumeralligamentsligaments

–– post. sup. labrum acts post. sup. labrum acts as the attachment of as the attachment of the post. capsule and the post. capsule and anchor for bicepsanchor for biceps

Shoulder InstabilityShoulder Instability-- AAnatomynatomy

Superior labrum + Superior labrum + biceps contribute to biceps contribute to stability (dynamic)stability (dynamic)–– PagnaniPagnani (JBJS, 1995)(JBJS, 1995)–– RodoskyRodosky (Am J (Am J

Sports Med, 1994)Sports Med, 1994)

resist ant and sup resist ant and sup translation of translation of humeral headhumeral headSLAP lesionSLAP lesion

Shoulder InstabilityShoulder Instability-- AnatomyAnatomy

IGHLCIGHLCAnterior band of Anterior band of infinfglenohumeralglenohumeral lig. lig. primary restraint primary restraint against anterior against anterior translation with the translation with the arm in 90 deg arm in 90 deg abductionabduction–– OO’’Brien, Am J Sports Brien, Am J Sports

Med, 1990Med, 1990

Shoulder InstabilityShoulder Instability-- AAnatomynatomySuperior Superior GlenoGleno--humeral Ligament + humeral Ligament + CoracohumeralCoracohumeral LigLig–– restraint to inferior restraint to inferior

translation and ER translation and ER w/ arm in adductionw/ arm in adduction

Middle Middle GlenoGleno--humeral Ligamenthumeral Ligament–– limits ER + inferior limits ER + inferior

translation in translation in adduction and ant adduction and ant translation in mid translation in mid abductionabduction

Shoulder Instability Shoulder Instability -- AnatomyAnatomy

Dynamic stabilizers:Dynamic stabilizers:–– Rotator cuffRotator cuff–– Shoulder girdle musculatureShoulder girdle musculature–– Biceps tendonBiceps tendon

Shoulder InstabilityShoulder Instability-- AAnatomynatomy

Others factors affecting stabilityOthers factors affecting stability–– Congruency of articular surfaceCongruency of articular surface

»» concavityconcavity--compression effectcompression effect–– Negative intraarticular pressureNegative intraarticular pressure

»» vacuum effectvacuum effect»» Warner et al, J ShoulderWarner et al, J Shoulder

and Elbow and Elbow SurgSurg, 1993 , 1993 (1cc free fluid)(1cc free fluid)

–– Rotator Cuff Rotator Cuff

Classification of InstabilityClassification of Instability

FrequencyFrequency–– AcuteAcute–– RecurrentRecurrent–– fixedfixed

DirectionDirection–– AnteriorAnterior–– PosteriorPosterior–– MultidirectionalMultidirectional

OnsetOnset–– TraumaticTraumatic–– AtraumaticAtraumatic–– OveruseOveruse

VolitionVolition–– VoluntaryVoluntary–– InvoluntaryInvoluntary

DegreeDegree–– DislocationDislocation–– SubluxationSubluxation

Shoulder InstabilityShoulder Instability

TUBSTUBSTTraumaticraumaticUUnidirectionalnidirectionalBBankartankart lesionlesionSSurgeryurgery

AMBRIAMBRIAAtraumatictraumaticMMultidirectionalultidirectionalBBilateralilateralRRehabehabIIf surgery, thenf surgery, thenIInferior capsular nferior capsular shift shift

Diagnosis of instabilityDiagnosis of instability

““Torn looseTorn loose””–– Instability in position of injuryInstability in position of injury–– Painless except in position of injuryPainless except in position of injury–– PE: apprehension, decreased resistance to PE: apprehension, decreased resistance to

load and shiftload and shift–– XX--ray: Hillray: Hill--Sachs, Sachs, glenoidglenoid lip lesionlip lesion–– Suggests ligament avulsionSuggests ligament avulsion

Diagnosis of instabilityDiagnosis of instability

““Born looseBorn loose””–– Instability in multiple positionsInstability in multiple positions–– Painful in mid positionsPainful in mid positions–– Diminished resistance to load and shiftDiminished resistance to load and shift–– XX--ray: no bony lesionray: no bony lesion–– Suggests that Suggests that glenoidglenoid is flattenedis flattened

Anterior Shoulder InstabilityAnterior Shoulder Instability

PathophysiologyPathophysiologyBankartBankart LesionLesion–– first described by A. Blundell first described by A. Blundell BankartBankart in in

19201920’’s, JBJS(Br)s, JBJS(Br)–– avulsion of the avulsion of the anteroinferioranteroinferior glenohumeralglenohumeral

ligamentligament--labral complex from the anterior labral complex from the anterior glenoidglenoid rim and scapular neckrim and scapular neck

–– present in about 85% of casespresent in about 85% of cases

The The BankartBankart LesionLesion

Anterior Shoulder InstabilityAnterior Shoulder Instability

Speer et al, JBJS, 1994Speer et al, JBJS, 1994–– Simulated Simulated BankartBankart lesion in cadaveric modellesion in cadaveric model–– Applied a 50Applied a 50--N ant load at various shoulder N ant load at various shoulder

positionspositions–– Max translation of 2.3mm at 0 degrees Max translation of 2.3mm at 0 degrees abdabd–– the the BankartBankart lesion alone is unable to account lesion alone is unable to account

for ant shoulder dislocationfor ant shoulder dislocation»» capsular stretch or capsular stretch or ligamentousligamentous insufficiency is insufficiency is

necessary for complete dislocationnecessary for complete dislocation

Anterior Shoulder InstabilityAnterior Shoulder Instability

HintermannHintermann and and GachterGachter, Am J Sports Med, , Am J Sports Med, 19951995–– arthroscopicallyarthroscopically assessed 212 shoulders w/ assessed 212 shoulders w/ >>1 1

dislocationdislocation–– 55% had 55% had glenohumeralglenohumeral ligament insufficiency or ligament insufficiency or

stretchingstretching

Capsular Laxity Capsular Laxity –– stretch injury to the capsulestretch injury to the capsule during dislocationduring dislocation–– may be may be plastically deformedplastically deformed

Anterior Shoulder InstabilityAnterior Shoulder Instability

The Standard:The Standard:Open Open BankartBankart repair with repair with CapsulorrhaphyCapsulorrhaphy

–– 3% recurrence rate3% recurrence rate–– Rockwood, in Rockwood, in Fractures in AdultsFractures in Adults, ,

19841984–– Review of the literature on 2,300 Review of the literature on 2,300

ptspts

Anterior Shoulder InstabilityAnterior Shoulder Instability

Open ProceduresOpen Proceduresdescriptiondescription problemproblem

BankartBankart gold standardgold standard

PuttiPutti--PlattPlatt subscapsubscap advancementadvancement limits ERlimits ER

MagMag--StackStack subscapsubscap----> > GrGr tubtub limits ERlimits ER

BristowBristow coracoidcoracoid---->>infinf glenoidglenoid nonunion, nonunion, migration, migration, recurrencerecurrence

Arthroscopic StabilizationArthroscopic Stabilization

StaplesStaplesTransglenoidTransglenoid suturessuturesBiodegradable tacksBiodegradable tacksSuture anchorsSuture anchors

Arthroscopic Staple RepairArthroscopic Staple Repair--ResultsResults

RedislocationRedislocation ResubluxationResubluxation

HawkinsHawkins 10%10% 3%3%MatthewsMatthews 8.3%8.3% --JohnsonJohnson 15%15% --MorganMorgan 5.2%5.2% --SweeneySweeney 10%10% --CoughlinCoughlin 17%17% 9%9%WilsonWilson 27%27% --

Shoulder InstabilityShoulder Instability

Problems with staple repairProblems with staple repair–– broken and migrated staplesbroken and migrated staples

»» 10% 10% reoperationreoperation rate to remove staplesrate to remove staples

–– articular injuryarticular injury–– high rate of recurrencehigh rate of recurrence

Arthroscopic Arthroscopic TransglenoidTransglenoidSuture Suture CapsulorraphyCapsulorraphy

Arthroscopic Arthroscopic TransglenoidTransglenoidSuture Suture CapsulorraphyCapsulorraphy

ArcieroArciero, Am J Sports Med, 1994, Am J Sports Med, 1994Prospective, nonrandomizedProspective, nonrandomized36 athletes w/ acute ant. shoulder 36 athletes w/ acute ant. shoulder dislocdisloc..NonoperativeNonoperative ((GrGr I) I) vsvs Arthroscopic Arthroscopic repair (repair (GrGr II) using II) using transglenoidtransglenoid suturingsuturingGroup I: 80% recurrent instabilityGroup I: 80% recurrent instabilityGroup II: 86% no recurrent instabilityGroup II: 86% no recurrent instability–– 1 pt required open repair1 pt required open repair–– 32 mo f/u32 mo f/u

Arthroscopic Stabilization using Arthroscopic Stabilization using the the BioabsorbableBioabsorbable TackTack

Arthroscopic Stabilization using Arthroscopic Stabilization using BioabsorbableBioabsorbable TackTack

Speer, Warren, et al (JBJS, 1996)Speer, Warren, et al (JBJS, 1996)–– 52 pts; 52 pts; aveave age 28age 28–– traumatic dislocation in 49 ptstraumatic dislocation in 49 pts–– BankartBankart lesion present in 50 ptslesion present in 50 pts–– 79% asymptomatic at 79% asymptomatic at aveave 42 mo post op42 mo post op–– 21% failed (4 from traumatic injury)21% failed (4 from traumatic injury)–– 8 pts required open 8 pts required open glenoidglenoid based based

capsulorrhaphycapsulorrhaphy

Arthroscopic Stabilization Arthroscopic Stabilization using Suture Anchorsusing Suture Anchors

KossKoss et alet al

Arthroscopic Stabilization Arthroscopic Stabilization using Suture Anchorsusing Suture Anchors

KossKoss et al, Am J Sports Med, 1997et al, Am J Sports Med, 1997Retrospective rev. 27 pts; Retrospective rev. 27 pts; aveave f/u 40 mof/u 40 mo70% good70% good--excellent resultsexcellent results30% had recurrent ant. instability30% had recurrent ant. instability (7 (7 from repeat traumatic event)from repeat traumatic event)Higher success in pts w/ 5 or fewer Higher success in pts w/ 5 or fewer dislocations before surgical dislocations before surgical reconstructionreconstruction

Assessment of Failed Arthroscopic Assessment of Failed Arthroscopic Anterior Labral RepairsAnterior Labral Repairs

MologneMologne et al, Am J Sports Med, 1997et al, Am J Sports Med, 199720 pts underwent open stabilization after 20 pts underwent open stabilization after failed arthroscopic procedurefailed arthroscopic procedure–– 10 10 transglenoidtransglenoid suturessutures–– 7 7 bioabsorbablebioabsorbable tackstacks–– 2 suture anchors2 suture anchors–– 1 arthroscopic screw1 arthroscopic screw

25% had 25% had reinjuredreinjured the shoulderthe shoulderaveave time to open procedure was 18 motime to open procedure was 18 mo

Arthroscopic stabilizationArthroscopic stabilization--AdvantagesAdvantages

reduced reduced postoppostop morbiditymorbiditydecreased hospital staydecreased hospital stayimproved assessment of improved assessment of intraarticular pathologyintraarticular pathologydecreased loss of ROMdecreased loss of ROMimproved improved cosmesiscosmesis

Multidirectional InstabilityMultidirectional Instability

BiBi--directionaldirectional–– Anterior inferiorAnterior inferior–– Posterior inferiorPosterior inferior

Global (Global (NeerNeer))–– Anterior, inferior and posteriorAnterior, inferior and posterior

Multidirectional InstabilityMultidirectional Instability

NeerNeer and Foster, JBJS, 1980and Foster, JBJS, 1980–– described anterior inferior capsular shift described anterior inferior capsular shift –– Reduces capsule volume on three sidesReduces capsule volume on three sides–– Thickens / tensions capsuleThickens / tensions capsule

AltchekAltchek and Warren, JBJS, 1990and Warren, JBJS, 1990–– TT--plastyplasty modification of the modification of the BankartBankart procedure for procedure for

MDI of the ant/MDI of the ant/infinf typetype–– BankartBankart repair and medial capsular shiftrepair and medial capsular shift

JobeJobe, Am J Sports Med, 1991, Am J Sports Med, 1991–– subscapsubscap split (sparring); capsular shift on split (sparring); capsular shift on glenoidglenoid

sideside–– imbricate sup over imbricate sup over infinf leafletleaflet--““bumper effectbumper effect””

Multidirectional InstabilityMultidirectional Instability

Inferior capsular shift from ant approachInferior capsular shift from ant approach

Multidirectional InstabilityMultidirectional Instability

Duncan and Duncan and SavoieSavoieArthroscopy, 1993Arthroscopy, 1993–– preliminary report on arthroscopic repairpreliminary report on arthroscopic repair–– described advancing the inferior capsule described advancing the inferior capsule

superiorlysuperiorly

Arthroscopic Capsular Arthroscopic Capsular PlicationPlicationfor MDI of the Shoulderfor MDI of the Shoulder

WichmanWichman and Snyder, Operative and Snyder, Operative Techniques in Sports Medicine, 1997Techniques in Sports Medicine, 1997–– 24 pts w/ >2 yr f/u24 pts w/ >2 yr f/u–– aveave age 26age 26–– no documented dislocationsno documented dislocations–– preserve ER to w/in 10 preserve ER to w/in 10 degrdegr preoppreop in 92%in 92%–– 79% satisfactory results79% satisfactory results–– 3/4 unsatisfactory results were worker3/4 unsatisfactory results were worker’’s s

compcomp

Arthroscopic Capsular Arthroscopic Capsular PlicationPlicationfor MDI of the Shoulderfor MDI of the Shoulder

Arthroscopic Capsular Arthroscopic Capsular PlicationPlicationfor MDI of the Shoulderfor MDI of the Shoulder

Capsular Shrinkage: The Laser Capsular Shrinkage: The Laser and and ElectrothermalElectrothermal TechniquesTechniques

NonNon--ablative heatablative heat–– Contraction of collagen is time and temp Contraction of collagen is time and temp

dependentdependent–– 6565--70 degrees C70 degrees C

PathophysiologyPathophysiology–– increased crossincreased cross--linking between fibrilslinking between fibrils–– changing helical structurechanging helical structure–– thermal thermal denaturizationdenaturization of collagenof collagen

ElectrothermalElectrothermal ShrinkageShrinkage

Increasing common procedureIncreasing common procedurePatients recover quicker; less morbidityPatients recover quicker; less morbidityImmobilization Immobilization –– critical for success!critical for success!–– Prevents rePrevents re--stretchstretch–– 3 wks 3 wks –– ant; 4 wks ant; 4 wks –– post; 6 wks post; 6 wks -- MDIMDI

AxillaryAxillary nerve neuritisnerve neuritis

Capsular Shrinkage: Capsular Shrinkage: Electrosurgical TechniquesElectrosurgical Techniques

3 devices commercially available3 devices commercially available–– OratecOratec–– MitekMitek–– ArthrocareArthrocare: bipolar effect which limits the : bipolar effect which limits the

depth of heat penetrationdepth of heat penetration

No clinical or basic science studies No clinical or basic science studies publishedpublished

Capsular Shrinkage: Capsular Shrinkage: Electrosurgical TechniquesElectrosurgical Techniques

Capsular Shrinkage: The LaserCapsular Shrinkage: The Laser

LACS: Laser assisted capsular shrinkageLACS: Laser assisted capsular shrinkageHo:YAG (m/c type)Ho:YAG (m/c type)–– Holmium doped crystal rod of Yttrium, Aluminum, Holmium doped crystal rod of Yttrium, Aluminum,

and Garnetand Garnet–– energy source: Krypton flash lamp energy source: Krypton flash lamp

Temperature control is difficultTemperature control is difficultmany studies show collagen shorteningmany studies show collagen shortening–– disrupts molecular bond stabilizing triple helix (disrupts molecular bond stabilizing triple helix (decdec

tensile strength; inc stiffness)tensile strength; inc stiffness)

Tissue Shrinkage w/ Ho:YAGTissue Shrinkage w/ Ho:YAG

First clinical series reported 1993/1994First clinical series reported 1993/1994MulticenterMulticenter study (5 practices) using Versastudy (5 practices) using Versa--Pulse Holmium laser (not peer reviewed)Pulse Holmium laser (not peer reviewed)Unidirectional and MDI without Unidirectional and MDI without BankartBankart1 joule, 10hz defocused beam, tangential 1 joule, 10hz defocused beam, tangential application w/ a 30 application w/ a 30 degrdegr probeprobe6 mo f/u6 mo f/u93% good93% good--excellent, 5% fair, 2% poorexcellent, 5% fair, 2% poorBetter results in younger, Better results in younger, subluxatorssubluxators, , nondominantnondominant armarm

Tissue Shrinkage w/ Ho:YAGTissue Shrinkage w/ Ho:YAG

Schaefer et al, Am J Sports Med, 1997Schaefer et al, Am J Sports Med, 199713 rabbit patellar tendons13 rabbit patellar tendons–– 300 J/cm2 dose to one tendon300 J/cm2 dose to one tendon–– contralateral tendon as controlcontralateral tendon as control

harvested tendons at 0 and 8 wksharvested tendons at 0 and 8 wkssignifsignif shrinkage (6.6% +/shrinkage (6.6% +/-- 1.4%) @ 0wks1.4%) @ 0wksincinc’’dd tendon length at 4 + 8 wkstendon length at 4 + 8 wksdecdec’’dd tendon stiffness @ 8 wkstendon stiffness @ 8 wksfibroblastic response w/ fibroblastic response w/ incinc’’dd cellularitycellularity

Tissue Shrinkage w/ Ho:YAGTissue Shrinkage w/ Ho:YAG