sci shoulder injuries
TRANSCRIPT
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Kevin Carneiro, DO
SCI Shoulder Injuries
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Outline
Shoulder function
Shoulder anatomy and kinematics
Shoulder function in SCI
Common shoulder pathologies
Rehabilitation and treatment of shoulder in SCI
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Epidemiology of Shoulder pain in
SCI
Prevalence of shoulder pain in tetraplegic patients ranges
from 30% to 78% (Curtis, 1999)
Prevalence of shoulder pain in paraplegic patients ranges
from 38% to 67% (Jain, 2010)
Tetraplegics have a higher prevalence than paraplegics
(McCasland, 2006)
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Functions of the Shoulder Girdle in
SCI patient
1. Connect the UE to the trunk
2. Provide mobility for UE
throughout space
3. Provide stability for skillful
movements of the elbow and
hand
4. AMBULATION
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STABILITY MOBILITY
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Mobility vs. Stability Conundrum
• Shoulder function is directly related to its high degree of mobility, but only when there is a preservation of stability • A degree of laxity necessary for large excursion of joint • Extensive ROM of the shoulder (relative to other joints) comes at the expense of anatomic and functional stability
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Shoulder
Complex
3 Joints
1 articulation
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Which one has more stability?
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Secondary stabilizers
Labrum and
Ligaments
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Secondary stabilizers
Muscles
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Anatomic position of shoulder girdle
Clavicle: 20° posterior to frontal plane
Scapular plane: 35° anterior to frontal plane
Glenohumeral joint: retroverted 30° posterior to medial-
lateral axis at elbow
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Scapulothoracic articulation Not a true anatomic joint
No osseous connection with the axial
skeleton
30-35° anterior to the coronal plane
Function: orient the glenoid for optimal
contact with the maneuvering arm
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Scapulothoracic Stability
Coracoclavicular ligament & muscles
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Scapulothoracic Mobility Observe medial inferior scapular border relative to spinous
processes
Elevation/Depression
Protraction/Retraction
Upward Rotation/Downward Rotation
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Scapular movements
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Rotator Cuff
GH Stabilization
Passive M tension
Dynamic Contraction
Maintain ideal center of
rotation b/w humerus and
glenoid
RC contraction can
stabilize an inherently
unstable shoulder
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Supraspinatus
O: Suprasp. Fossa
I: Gr tuberosity
Abduction
Able to fully abduct shoulder
without supraspinatus
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Infraspinatus & Teres Minor
O: Inferior scapula
I: Greater tuberosity
Ext Rot
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Subscapularis
O: Costal scapula
I: Lesser Tuberosity
Int Rot
Ant Stabilizer in 45° abduction
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Integrated Muscular Activity
Every shoulder movement involves
collective contributions from
agonist and antagonist M’s
Force couple = relationship
between the M’s creating a specific
movement
Allows rotation around a fixed axis
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Scapular retraction force couple
Middle and lower trapezius + rhomboids cooperate to retract the scapulo-thoracic joint
The dashed line indicates the net retraction force
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Subscapularis: Infraspinatus Couple
Transverse Plane
In internal rotation,
infraspinatus provides and
equal and opposite F with
eccentric contraction
Keeps humerus on glenoid
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Scapular Rotation Force Couples
Upward
Rotation
Upper
trap+
upper SA
Lower trap
+ lower SA
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RC and deltoid force couple
Deltoid and RC muscles
contract at initiation of
shoulder abduction
RTC muscles resist
superior glide to
maintain center of
rotation
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+ =
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Scapulohumeral Rhythm- Abduction
GH responsible for 120 degrees
Scapulothoracic responsible for 60 degrees
Ratio ranges from 4:1 to 1:1
If GH motion is limited- arm unable to abduct
more than 60 degrees
Frozen shoulder – reverse scapulohumeral
rhythm (“shoulder hiking”)
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Shoulder Girdle Rhythm - Abduction
Full 180 degrees requires motion
at all 4 joints
Phase 1: humerus elevation with 5°
clavicular elevation
Phase 2: humerus abduction,
scapula elevation, clavicular
elevation and rotation at the AC
and SC joints
Phase 3: humerus abduction and
rotation, scapula rotation, clavicle
rotation and elevation
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Kinetic Chain and Shoulder Motion
Contralateral bending
through the spine – higher
reach
Serrape effect: Contralateral
hip and shoulder are
connected through core
muscles
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Shoulder Complex Summary
3 joints + 1 articulation
Glenoid moves to accommodate humeral head
Mobility > stability
Dynamic stability depends on force couples
If dynamic stability (RC and scapular
stabilizers) is compromised– multiple
structures are at risk of injury
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THE NON-TRAUMATIC SHOULDER Epidemiology:
Shoulder pain – third most common reason to visit a physician (behind LBP, HA)
~ 40%-45% of ASx patients > 50 yoa have ptl or full-thickness RTC tears
~ 3% incidence of Adhesive Capsulitis in population; F > M ; 5x greater risk in DM
Difficult to estimate prev/ incidence of “Instability” or “Scap Dysfunction” since there are broad spectrums for both
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Uniqueness of the SCI patient
Wheelchair use
Repetitive motion
GH joint not built for stability
tend to sit in a kyphotic posture
scapula changes its vertical alignment
rotates in the sagittal plane forward and downward, depressing the
acromial process and changing the facing of the glenoid fossa.
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Uniqueness of the SCI patient
Level of injury
higher the level, more shoulder pain
superior push force in the tetraplegics
weakness of thoraco-humeral depressors
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Principles: What are the main
pain generators?
Glenohumeral joint capsule
Acromioclavicular joint
Biceps Tendon
Subdeltoid Bursae
Sternoclavicular joint
Referred pain
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Rotator Cuff Injuries
Impingement
Tendinitis
Partial/ full tear
Tendon degeneration
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Impingement
Jobe & colleagues classification:
Grade I: Pure impingement with no instability
Grade II: Secondary impingement & instability caused by chronic capsular and labral microtrauma
Grade III: Secondary impingement and instability caused by generalized hypermobility or laxity
Grade IV: Primary instability with no impingement
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Impingement
Most often affects:
Supraspinatus tendon
Subacromial Bursae
Biceps Tendon
Can get subdeltoid bursitis from accelerated throwing phase
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Impingement
Usually pain through arc of motion 60-120° +/- weakness
Mechanical compression of tendons between humeral head and
coracoacromial arch
Irritation of the rotator cuff tendons results in inflammation and
damage to the tendons.
Etiologies:
- extrinsic (primary, secondary)
- intrinsic
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Primary external impingement
superior structures of the subacromial space encroach the tendons from above = stenotic acromial morphology - Bigliani classification:
o Type I- flat 17%
o Type II- curved 43%
o Type III-hooked 39%
osteophytes form on acromion itself or undersurface of AC joint.
With age, thickening of the coracoacromial arch can occur.
90% of cases are from stenotic impingement
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Acromion Anatomical Variants Type III most associated with Impingement/RTC tears
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Secondary external impingement
Often in younger people.
Decreased subacromial space secondary to instability
Ex – when the muscles attaching to medial border of the scapula do not adequately control protraction and rotation of the scapula with glenohumeral movement, anteroinferior movement of the acromion results.
Ex - imbalance between the deltoid (humeral head elevation) and the rotator cuff muscles (humeral head stabilizers) may also lead to narrowing of the subacromial space leading to impingement; (NOT ONLY strength imbalance, BUT ALSO motor control/sequence)
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Internal impingement
Internal or glenoid impingement can occur in the overhead athlete during the late cocking phase (extension, abduction and external rotation) when impingement of the rotator cuff occurs against the posterior-superior surface of the glenoid.
Although the above is a physiologic occurrence, it becomes a problem in the overhead athlete due to repetitive microtrauma. (i.e., I = NF/AR)
Hypovascularity of the tendon may lead to degeneration at the insertion site. Often distal to “critical zone” of tears
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Rotator cuff terminology
Tendinitis: active inflammation.
Tendinosis: collagen degeneration, fiber necrosis, and
neovascularization.
Tendinopathy: any pathology/abnormality.
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Rotator cuff tendinopathy Symptoms: pain with overuse, overhead activities or from
excessive load due to altered or faulty body mechanics. Activities
less than 900 degrees are usually pain free.
May have history of sx of instability
Impingement of the rotator cuff tendons may restrict blood
supply and promote tendinopathy
Get associated subacromial bursitis decreased subacromial
space and inflammation. Often treated the same way (similar
symptom complex)
condition easily becomes chronic
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Rotator Cuff Tears
Complete or partial tears of the rotator cuff common in older adult athletes. This is likely due to a process of degeneration.
pain and an inability to sleep on the affected side. Exam may reveal weakness and wasting of the rotator cuff muscles.
MRI is usually helpful in confirming the diagnosis (caveat: up to 54% prevalence in Asx >60 years; Murrell and Walton, 2001; Morland et al., 2003)
Small tears can usually be treated conservatively.
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Examination highlights Tenderness to palpation of supraspinatus tendon
Painful arc- approx between 70 and 120 degrees (some say 45 for supraspinatus) (95% sens, 60% spec)
Impingement tests: Neer, Hawkins/Kennedy, and modified Hawkin’s (both 85-90% sens, low spec)
Bicipital tendinopathy: Speed’s, Yergason’s
Rotator cuff pathology: drop arm test (98% spec), empty can test (supraspinatus test – 64% sens)
Shoulder IR often reduced
May have AC joint tenderness
May have edema and hemorrhage with tears
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Shoulder examination
Other: neural tension manuevers, Adson’s maneuver for “TOS”, Spurling’s test for cervical nerve root irritation, and many more.
Look up and down the kinetic chain- i.e. Cervicothoracic contribution, spine motion, Hip ROM and hip girdle control, Foot/Ankle in throwing/overhead athlete
Murrell and Walton in 2001 reviewed 23 clinical examinations for rotator cuff tears:
found if Supraspinatus, Ext Rot weakness, and impingement were all +, or if two signs are + and the patient > 60 years the chance of ptl or full cuff tear is 98%
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X-rays- impingement series AP shoulder - with impingement may see cystic changes of greater tuberosity with chronic RC tear may see superior migration of
humerus (<6mm subacromial interval)
AP in ext. rot. brings greater tuberosity into clear prominence; measurement of the acromiohumeral interval more
accurate with external rotation view
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AP shoulder The normal interval
between the acromion
and the humerus is
between 7 to 14 mm.
A decrease in this
distance (to less than 6
mm) may be indicative of
a rotator cuff tear.
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Rotator Cuff Tear
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Impingement series Axillary view- may show lack of posterior
translation due to anterior instability.
Scapular outlet view( 15 degrees scapular tilt
froma transcapular Y view)- used to evaluate the
subacromial space and the supraspinatus outlet
from the lateral view
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Other Imaging Ultrasound- evaluate the rotator cuff. Can give you
images with dynamic movement. (equivocal sensitivity and
specificity to MRI for RTC, Teefey et al, JBJS, 2004)
MRI- evaluate the cuff (best fat suppressed FSE T2-weighted, otherwise think fat plane is a full thickness tear), other soft tissue and bony structures
MR arthrogram- evaluate the cuff (close to 100% sens
for full tear), labrum/capsule. May see contrast extending into bursae
CT arthrogram option if can’t get MRI
Arthroscopy- surgical evaluation
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Supraspinatus tear – MR arthrogram http://uwmsk.org:8080/UWR/stories/storyReader$41
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Treatment of RTC injuries Ice
Change/decrease overhead activities
Anti-inflammatory meds
Exercises focused on humeral head stabilizers and strengthening scapulothoracic stabilizers. Change program as pt progresses. HEP
Steroid injections (caution of tendon rupture) 10cc of 1% lidocaine. Could use with subdeltoid bursitis if needed.
massage therapy - digital ischemic pressure over the tendon near its insertion progressing to transverse friction
Surgical decompression – anterior acromioplasty, C-A Lig release, spur shaving
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Treatment
Re-evaluate in one year if not improving – may be
different etiology (early adhesive capsulitis)
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Treatment-scapular stabilization Important because acromial elevation and scapular
stabilization is often jeopardized due to painful inhibition of the serratus anterior and the lower trapezius.
Also may have alteration of the position of the scapula to accommodate injury patterns in subluxation or impingement (sustitution/compensation).
initially done in the closed kinetic chain-especially in situations where instability is present.
many conditions contribute to overload, therefore isolated rotator cuff exercises frequently not successful in relieving the clinical symptoms.
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Scapular stabilization-CKC
emphasizes co-contraction of force couples at the scapulothoracic and glenohumeral joints.
reduces the shear at the GH joint created by isolated rotator cuff activation.
CKC scapular movements help to re-establish normal neurologic patterns for joint stabilization.
decreases deltoid activation, decreasing the tendency for superior humeral migration and providing a stable scapular base when the rotator cuff is weak.
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Treatment Exercises Re-establish the kinetic chain early.
Correct inflexibilities of the hip and trunk.
Address weakness or imbalances of the trunk rotators as well as flexors and extensors of the trunk and hip.
Address any subclinical adaptations of the stance or gait patterns.
Eccentric forces should be emphasized to address the movement patterns of a particular sport.
Crossed patterns from the hip to the shoulder should be addressed as most shoulder activities involve rotation and diagonal patterns.
Postural training- cervical, thoracic- to ensure normal positioning of the scapula. Thoracic Kyphosis predisposes to impingement symptoms due to downward rotation/anterior tilt of the scapula
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Additional treatment focus
Neural mobilization techniques(Sliders)
Balance/proprioception training
“Econcentric Muscle Function” = agonist/antagonist function for each movement (Gary Gray 2000)
Education of HEP, biomechanics, and prevention.
Posterior capsule stretching. Posterior capsule tightness is often present which needs to be addressed.
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Instability
Anterior instability
Posterior instability
Multidirectional instability
Primary – Marfan’s, Ehler-Danlos
Secondary – repeat dislocations, hx trauma, chronic overuse
Spectrum Disclocation, Subluxation, Laxity
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Instability complex A cascade of pathologic events initiated by
instability resulting in anterior translation/ subluxation, followed by impingement of the rotator cuff and eventually rotator cuff tear.
Jobe (1989)acknowledges the instability complex but notes that instability and impingement do not always occur in this fashion.
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Atraumatic Instability
Age 10-35
Pain & instability with activity
No trauma but repetitive overhead activities
(tennis, swimming, baseball, painting)
Full or excessive AROM
Normal or excessive PROM
Normal resisted isometric movement
Hx of recurrent anterior subluxation
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Anterior instability May be result of trauma i.e., post acute subluxation or anterior
dislocation
From gradual stressing of the static components with persistent activity through the full ROM
Can have “dead arm syndrome”- from traction or impingement in the neurovascular structures causing transient numbness or weakness of the arm
may have more frequent episodes where reaching or yawning may result in a feeling of instability or subluxation (i.e., apprehension).
Rehab focus should be on Subscap/ Int. Rot.
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Instability
Anterior translation of the humeral head may result in labral tears (esp. if combined with ER peel back mechanism) Superior Labrum, Anterior and Posterior (SLAP)
Anatomic endpoint is reached in external rotation resulting in bony changes of the humerus
The capsule itself may separate from the glenoid Bankhart – anteroinferior glenohumeral ligament
attachement at labrum is torn
Hill-Sach’s –avulsion fracture of the posterior humeral head
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Posterior instability
In atraumatic cases, mostly seen with multidirectional instability via marked posterior drawer test.
Usually responds well to conservative measures.
In overhead throwing – difficult to distinguish from anterior instability since pain occurs from both in the same phase.
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Multidirectional instability Multidirection instability is usually
due to general ligamentous laxity.
Assessed again with AP load and shift
test. There may be “sulcus sign” with
inferior traction.
Rehab is similar except for
avoidance of stretching of the
shoulder girdle muscles.
If patients fail conservative
treatment, they traditionally don’t
respond to surgery as well as post-
traumatic instability.
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Physical examination highlights
Specialized tests: apprehension is not pain
The anterior capsule is stretched and the posterior capsule becomes tightened.
Should try to note any general ligamentous laxity.
Beighton scale for hypermobility
Monitor scapular instability too (wall pushup) “snapping” or shifting scapula
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Shoulder instability exam
Instability Tests:
Apprehension test – Relocation
Load and shift test
Sulcus sign (multidir)
Labral
O’Brien’s active compression tests (SLAP)
Anterior slide test (Bankart)
Clunk (Bankart)
Resisted supination external rotation (SLAP)
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Beighton scale for hypermobility
The 9 Point Beighton Scale is as follows.
* Thumb to forearm (1 point for each arm so possible total of 2),
* Elbows hyperextending to 10degrees or beyond (1 Point for each arm
for a total of 2 points)
* Palms flat to floor with legs straight (1 point)
* Knee hyperextending to 10 degrees or beyond (1 point for each leg
for a total of 2 points)
* bending little fingers back to 90 degrees or more (1 point for each
hand for a total of 2 points)
For a total of 9 points. a score of > 5 is indicative of Hypermobility.
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The Apprehension Test
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Sulcus Sign
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Load and Shift Test
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Humeral Head Translation
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X-rays-Instability series Instability Series:
AP of Shoulder True AP-Grashey- also w/ 35 deg E.R. Axillary View -assess glenohumeral disclocations Stryker Notch View - assess Hill-Sachs lesions West Point Axillary View - osseous bankart defect on anteroinferior glenoid rim is best picked up with this
view
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Stryker Notch view To evaluate for Hill-Sachs Lesion
of lateral humeral head after dislocations;
Technique - the patient is supine - a cassette is placed under the
involved shoulder - the palm of the hand of the affected extremity is placed on
top of the head with the fingers toward the back of the head;
- the beam is centered over the coracoid process and tilted 10 deg cephalad;
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CT arthrogram of Hill-Sach’s (Broca) Deformity http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kellyus.shtml
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Bankart lesion http://www.steadman-hawkins.com/shoulder3/diag.asp
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Bankart lesion http://uwmsk.org:8080/UWR/stories/storyReader$409
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Treatment of Instability Reduce dislocation – neurovascular testing
Sling protection for few weeks
Within several days - Active assisted exercises for dynamic stabilizers and periscapular muscles
Surgery usually reserved for presence of neurovascular compromise
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Adhesive Capsulitis Aka “frozen shoulder” or pericapsulitis
Age 40 plus
More common in women
Functional restriction of external rotation,
abduction, and medial rotation but can get
general pain with decreased AROM/PROM in all
planes
No pain with resisted isometric movement when
arm is adducted near body
Muscle atrophy early in course
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Adhesive capsulitis
Often idiopathic (16%-20% bilateral within 5 years) associated conditions: (not in order of prev) - Immobility (most common risk factor) - 40-60 yo - Female - Diabetes - Thyroid disease - previous trauma - hyperlipidemia - inflammatory arthritis - intracranial lesions - Parkinson’s disease - cervical disc disease
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Adhesive capsulitis pathophysiology Inflamed synovium
Adhesions
Decreased acromio-humeral interval
Chronic fibrosis
Contracted dependent axillary fold and surrounding soft tissue
Tight capsule thickens and sticks to anatomic neck
Suggestion of neurologically mediated pain and ischemic
component
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Adhesive capsulitis Stages:
1) Painful: progressive vague pain, lasts approx 8 months (2-
9).
2) Stiffening: decreasing ROM lasting approx 8 months (4-
12).
3) Thawing: an increase in ROM with decrease in pain.- some
feel this is the stage at which therapy can be most helpful. Can
last up to 42 months.
90% get better after 2 years
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Shoulder exam Diagnosis – clinical (rule out common
etiologies)
Early –
pain in end range (capsular pattern)
may have multiple + PE findings for rotator cuff/
impingement – hard to distinguish
Later – less pain and worsening PROM
restriction from contractures
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Adhesive capsulitis-imaging Plain films to rule out other underlying causes.
-- May appear osteopenic.
Arthrogram reveals:
- Decreased capsular volume Normally can inject 16-20 cc of dye, with adhesive
capsulitis takes 5-10 cc
- Obliteration of axillary fold
- Lack of filling of the subscapular bursae
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Adhesive capsulitis treatment medications-NSAIDS/corticosteroid injections,
analgesics (suprascapular nerve block?)
modalities- ice, ultrasound, TENS (limited
efficiency)
therapy- pendulum>>>wall climbing. Exercises
are focused on increasing ROM (passive
stretching first) and muscle strengthening.
MUJA
surgery- rare for recalcitrant cases