Primary rotator cuff disease: stage 1
Oedema and Haemorrhage
- Repetitive overload and overuse of tendons in overhead activities - tendons become inflamed and swollen
- Seen more in younger athletic patients and is reversible
Could be repetitive overhead eccentric load or an acute trauma
Swelling/oedema - decreased ed subacromial space or nociceptive pain
Primary rotator cuff disease: stage 2 (tendinopathy)
From repeated episodes of inflammation
Results in thickening or fibrosis of sub-acromial bursa/surrounding capsule and ligaments = intra-tendinous degeneration
Age between 25-40 years
+ Chronic swelling in bicipital groove
Primary rotator cuff disease: stage 3 (partial/full thickness tears)
More common in elderly
Presentation varies depending on…
- What tendon is torn
- If one or more tendons are torn
- Whether it is a complete or partial tendon rupture
MOI
- Spontaneous or minimal trauma
- Repetitive trauma
Partial Thickness tears
Superior surface
- Often linked to sub-acromial pain and limitation of movement
- Underlying 1 and 2 degrees of compressive micro and superimposed macro-trauma
Under-surface/articular side (most common site for tears)
- Linked to tensile loads and GHJ instability
- Common in overhead throwing athlete
- Includes posterosuperior
Risk factors and consequences of RC degeneration/tears
Risk factors
- Smoking
- Excessive alcohol consumption
- Obesity
- Hypercholesterolaemia
- Family history
- Pain highly correlated with progressive/increasing tear size
- Limited ability for RC tears to heal spontaneously
Consequences
- Can tear other muscles at the same time
- Functional limitations/symptoms will vary depending on the section torn
- May also cause concurrent instability if there are multiple tears
- Biomechanical consequences: loss of ER, IR and Abd strength
- Can cause antalgic posture
- Affect ability to maintain prime HOH position
- Can affect other structures
Posterosuperior RC pain syndrome and impingement
Excessive or reptitive contact between the posterior aspect of the greater tuberosity of the humeral head and the posterior-superior aspect of the glenoid border when the arm is placed in extreme ranges of abd. and ER in the scapular plane
Compression of deep surface of the RC (IS and TM) on the postero-superior border of the glenoid occurs causing articular side tears of IS and TM
Area of pain - posterior acromion, diffuse deep internal GH joint ache
Diagnosis:
- AP (posterior drawer) glide
- Pain
- Loss of strength and/or ROM
- Stop sign test (TM, IS) @ 0 and 90 degrees of abduction
- Posterior pain reproduction
- Jobe’s, Hawkins, Neers,
GIRD
Glenohumeral internal rotation deficit > 20 degrees difference between dominant and non-dominant
- Sport specific adaptation of posterior shoulder structures in response to chronic overload from repetitive throwing
- From contracture/shortening of posterior capsule
- From contracture/shortening of posterior capsule
- ? From adolescent bone adaptation to shape of Humerus
- From hypertonicity in ER from repeated eccentric loading
Calcific tendonitis
Calcific deposit in RC tendons
Usually in supraspinatus
Original cause unknown
Manifests as shoulder impingement
GHJ OA
Progressive degenerative changes in joint cartilage/labrum bony surfaces/subchondral bone (formation of subchondral cysts)
Signs and symptoms
- Pain in GHJ +/- AC joint
- Stiffness end of range of movement: flexion/abduction/ER/HBB
- Early arm stiffness
- Progressive restriction of movement and weakness
- Clicking and grating
- Loss of functional ability
- Previous history (Injury to GHJ, occupation)
- End stage (surgery)
SLAP
Superior Labral Anterior to Posterior
May occur with chronic overuse injuries and acute
Overhead throwing athletes can tear anterosuperior section of the labrum with repeated throwing
MOI
- In abducted/ER position - where the long head of biceps angled posteriorly (produced a twist at the attachment of the bicep tendon, can cause labrum to rotate medially and peel off)
- Follow through phase of throw when eccentric biceps contraction involved with deceleration at release of throw
Diagnosis:
- Pain provocation test
- Posterior capsule length test, -Obrien’s and biceps load test (labrum)
- Yergusons
- RC (empty can, IR, ER and abdominal bears test)
Treatment:
- Low load for first 8 weeks
- Scapular control (retraction isometric hold)
- RC build-up (IR and ER gravity minimised)
- More biceps progression (ER flexion and progressing into supinated position)
Hypermobility GHJ
Can be general hypermobility disorder (HSD) or isolated GHJ hypermobility
HSD - Beighton score
Asymptomatic = joint laxity
- Excessive translation HOH along glenoid/+ve load and shift test
- Able to subluxate/dislocate GHJ/SCJ
- Increases wear/tear
Symptomatic (secondary manifestations) from macro and microtrauma = joint instability
Diagnosis: -Pain/instability/weakness provocation on apprehension test Treatment -Neuromuscular control -Strength
MDI
Multidirectional instability
Causes
-General hyperelasticity
Lax in all directions but may only be symptomatic in 1 direction
Hypermobility on other side is asymptomatic
Inferior translation will tension superior capsule and SGHL/CHL
Diagnosis
- Positive pain apprehension tests
- Positive translational tests including sulcus sign
Anterior dislocation
MOI
- Forced abduction and ER
Involves damage to capsular structures
May also include labral, bony, ligamentous and muscular damage
90-95% of all dislocations
Diagnosis
- Deformity
- Pain
Treatment
- <20 years: anterior reconstruction
- > 20 years: conservative rehab first
Posterior dislocation
Direct blow to shoulder or fall onto an outstretched arm with arm positioned in internal rotation and adduction
Diagnosis
- Deformity
- Pain
- TOP
Anterior GHJ instability
Result of either trauma (dislocation/subluxation)/repetitive overuse/incorrect technique that causes microtrauma to anterior capsule to the stage where the tissue does not recoil to normal length
Allows increased anterior translation of humeral head in abd/ER which may involve pain
Diagnosis
- ROM can be hypermobile
- Apprehension/relocation test
- Increased anterior excursion in PA glides
- TOP of posterior structures
Posterior instability
More common in sports populations
- Apprehension in flexion/IR/adduction (Humerus ‘dumps out the back’ on arm elevation
- Pain posterior shoulder feeling of instability/lack strength with throw
Diagnosis/presentation
- Pain posterior but also anterior due to stretch of structures
- Crepitus/clicking/catching/subluxation/feeling of instability
- Full/excessive ROM
- Subluxation test
- Loss of normal appearance of the front of the shoulder
Adhesive Capsulitis (frozen shoulder)
Idiopathic, Insidious onset
More common in females then men
No gold standard in diagnosing early phase FS
More commonly seen unilaterally
Increase in severe pain and progressive loss of movement
Loss of active and passive movement - ER > abduction > IR
3 stages: freezing, frozen, thawing
No intra-articular fluid, capsule adheres to humeral head and inferior fold sticks together
Painful (freezing) stage and its treatment
Pain ++ with movement
Generalised ache that is difficult to pinpoint
Muscle spasm
Increasing pain at night and at rest
Treatment:
- AAROM
- PROM (posterior capsule - IR, ER, across body adduction, abduction, elevation) - 5 sets, 5 reps
- PA glides (grade 1 and 2)
- Steroids
- NSAIDS
- Heat before therapy
Adhesive (frozen) stage and it’s treatment
Less pain
Increasing stiffness and restriction of movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges of movement
- Want full ROM
- Chest stretches
- Strengthening and mobility exercises for scapular setting
- Abduction, ER, IR, elevation retraction, adduction (start with isometrics and progress)
- 8 reps, 3 sets
Recovery (thawing) stage
- Decreased pain
- Marked restriction with slow, gradual increase in ROM
- Recovery is spontaneous but frequently incomplete
- Full ROM
- Lots of stretching of chest muscles
- Adding weight and/or resistance
- Postural and kinetic chain exercises
Fractures of Humerus
Most common MOI
- FOOSH
Diagnosis
- X-ray
Treatment
- Conservative with sling and rehab
- Surgery such as trimed fixation
