Shoulder Pathology

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  1. Upper Quarter Screen: Dermatomes
    • C4 = AC Joint
    • C5 = Lateral Cubital Fossa
    • C6 = Palmar Thumb
    • C7 = Palmar Phalanx Middle Finger
    • C8 = Palmar Phalanx 5th Digit
    • T1 = Medial Forearm
  2. Upper Quarter Screen: Myotomes
    • C1 = neck flexion
    • C3 = neck side flexion
    • C4 = shrug 
    • C5 = abduction
    • C6 = elbow flexion
    • C7 = elbow extension
    • C8 = thumb extension
    • T1 = interossei
  3. Upper Quarter Screen: Reflexes
    • C4 = Levator Scapulae
    • C5 = Deltoid
    • C6 = Biceps
    • C7 = Triceps
    • C8 = Extensor Pollicis Longus
    • T1 = Thenar Muscles
  4. Pancoast's Syndrome
    • Tumor invades upper chest wall (upper 2 ribs) & brachial plexus
    • c/o scapular and shoulder pain
    • Radicular symptoms to C7, C8, and T1
    • Sensory changes (ulnar nerve)
    • Passive neck side flexion to contralateral side = limited and painful
    • Isometric side flexion to ipsilateral side = painful and weak
    • Potential absent triceps reflex
  5. C7-T1 Metastases
    • Lung, breast cancer, and lymphoma
    • Pain in paraspinal region radiating to both shoulers
    • Tenderness over spinous process
    • Nerve root compression - C7, C8, T1

    • *Intrinsic hand weakness, triceps, wrist flexors
    • *Numbness & paresthesia
  6. Diaphragm
    • Innervated by phrenic nerves
    • C3, C4, C5 (motor and sensory)
    • Diaphragm compression can refer pain to shoulder (Supraclavicular nerve C3-C4)

    Liver, spleen, gallbladder, compression of diaphragm → sensory fibers (phrenic n.) receive pain signals → signals to spinal cord C3,4 and 5 → brain perceives signals → sends pain sensation to shoulder
  7. Organ Referred Pain Locations
    • Right Shoulder: Liver & Gallbladder
    • Left Shoulder: Spleen
  8. Axillary Nerve Injury
    • Mechanism: shoulder dislocation
    • Atrophy of deltoid
    • Sensory changes in C5 dermatome (inferior region of deltoid (sup. lat. cutaneous n.))
    • Motor changes in C5 dermatome (deltoid, teres minor)
  9. Cervical Spine Special Tests
    • Spurling:
    • Pt. moves neck into ext, lat flex, and rotation towards side of pain
    • Downward compression applied to head
    • (+) = radicular pain or paresthesia in dermatomal distribution (secondary to pressure on inflamed nerve root/spinal cord)

    • Bakody's Sign:
    • Cervical nerve C4-C5
    • Raise affected arm over head to rest on top
    • (+) nerve compression if relief of radicular symptoms
  10. Osteoarthritis: Structural Changes
    • Flattening, erosion posterior glenoid
    • Posterior subluxation of humeral head
    • Deformed humeral head shape
  11. Osteoarthritis: Mechanisms
    • Mechanical - RC tear, AP instability, long head biceps tear
    • Nutritional - inadequate diffusion, diminished synovial fluid
  12. Rheumatoid Arthritis
    • Systemic inflammatory disease of connective tissue
    • Synovial inflammation of subacromial - sub deltoid bursa

    • Symmetric involvement
    • Painful abduction w/ shoulder to 90 degrees bilaterally
    • Long term corticosteroid use → RC tear
  13. AC Joint Arthrosis: Causes
    • Degenerative (often seen w/ RC pathology or impingement) 
    • Post-traumatic (fall on outstretched arm)
  14. AC Joint Arthrosis: Presentation
    • C/O local pain (directly over AC joint)
    • Pain w/ flexed-adducted position, over head motion
  15. Adhesive Capsulitis: Types
    Primary: idiopathic (insidious onset; unilateral)

    • Secondary: associated w/ known condition
    • Post traumatic (immobilization)
    • Disease process (diabetes, post-mastectomy, RA, CVA/hemiplegia)
  16. Adhesive Capsulitis: Mechanism
    Trigger → inflammation of synovium & jt capsule → capsular fibrosis (collagen deposition) → decreased intra-articular volume/capsular compliance (humeral head tight against glenoid fossa) → global loss of AROM/PROM
  17. Adhesive Capsulitis: Stages
    • Stage I & II: Painful Stage - "Freezing"
    • Progressive loss of motion w/ consistent pain
    • Capsular pattern: ER → And → IR (global motion loss)

    • Stage III: Adhesive Stage - "Frozen"
    • Stiff restricted shoulder w/ minimal pain
    • Compensatory motions - decreased inf. glide → shoulder hike

    • Stage IV: Recovery Stage - "Thawing"
    • Slow, gradual increase in ROM
    • Recovery is spontaneous but frequently incomplete
  18. Stability of GH Joint
    Static components: capsular ligaments, labrum, intra-articular pressure

    Dynamic components: rotator cuff, deltoid, long head of biceps
  19. Complications of Instability
    • Hill-Sachs Lesion
    • Dislocation: compression fracture on posterior humeral head @ site of impact on inferior glenoid rim
    • Subluxation: repetition of contact between humeral head & glenoid (lesion on posterior humeral head)

    • Bankart Lesion:
    • Avulsion of anterior inferior labrum from glenoid rim

    Tears (RC, SLAP)

  20. Instability: Clinical Presentation
    • Subjective reports of "clunk" or "click"
    • Subjective reports of "dead arm" or general heaviness (SLAP)
    • Diffuse soreness → multidirectional
    • Pain location dependent on area of instability
  21. Instability: Clinical Tests
    • Sulcus Sign
    • Posterior Instability
    • Anterior Instability
    • Apprehension
    • Relocation
  22. Impingement: Types
    Primary: static (outlet impingement)

    Secondary: dynamic, repetitive microtrauma (extrinsic)
  23. Primary Impingement
    • Static
    • Subacromial outlet impingement (mechanical impingement of RC tendon beneath acromion; secondary to compromise of subacromial outlet space)
    • *Subacromial outlet contains humeral head, acromion, coracromial arch & acromioclavicular ligament 

    • Causes:
    • Acromion shape (curved or hooked)
    • Acromioclavicular osteophytes 
    • Thickening of coracromial ligament
  24. Primary Impingement: Classification
    Neer's Three Stage Classification:

    • Stage I: younger patients (<25); acute inflammation
    • Stage II: ages 25-40; fibrosis and tendonitis 
    • Stage III: >age 40; partial/complete RC tear; osteophytes at coracromial arch
  25. Primary Impingement: Clinical Presentation
    Pain reported w/ forward flexion and IR position (elevation) -- greater tuberosity approximates acromion & coracromial arch

    Typically older patients
  26. Primary Impingement: Clinical Tests
    • Neer Impingement
    • Hawkins-Kennedy Impingement Test
  27. Secondary Impingement
    Dynamic: relative narrowing of outlet secondary to abnormal humeral head movement w/ activity

    • Mechanism:
    • → RC imbalance (weakness,tear)
    • → Ligamentous instability 

    • Clinical Presentation:
    • →Typically younger patients
    • Symptoms activity specific (overhand activities)
  28. Labral Tears: Types
    • Type I: Fraying of labrum (degenerative)
    • Type II: Detachment of superior labrum & origin LHB
    • Type III: Bucket handle tear (labrum torn and displaced into joint)
    • Type IV: Bucket handle that extends into biceps tendon 

    • *Type III and IV: linked to traumatic instability
    • *Type II and IV: result in instability of biceps-labral anchor (more common!)
  29. Mechanism of SLAP Injury
    • Fall onto outstretched arm (FOOSH) - compression injury
    • Traction tension on biceps tendon (LHB attaches to labrum in 50% of population)
  30. Labral Tears: Clinical Tests
    • Crank Test: (+) = symptomatic click or grinding or clunk
    • O'Brien Test: (+) = relief of pain or popping w/ 2nd test position (sensitive and specific!)
    • Biceps Load II: (+) = pain w/ resisted elbow flexion
  31. Labral Tear: Clinical Presentation
    • Biceps pain w/ elbow flexion
    • Pain w/ overhead activities 
    • "Dead arm" when throwing
    • Occasional popping/clicking in the shoulder
  32. Rotator Cuff Tear: Mechanisms
    • Compression (space attrition; instability → impingement)
    • Tensile overload
    • Macrotrauma
  33. Rotator Cuff Tear: Clinical Tests
    • Drop Arm Test
    • Lift Off Test
    • Belly-Press Test
    • External Rotation Lag Sign
  34. Bicipital Tendonitis
    • LHB = attachment to labrum, SLAP
    • → Stabilizes and decelerates in throwing 

    Mechanism → Tendonitis (impingement - passes beneath anterior edge of acromion

    Subluxing LHB - tear of transverse humeral ligament
  35. Bicipital Tendonitis: Clinical Tests
    Speeds Test
  36. Bursitis
    • Primary - associated w/ systemic disease, degenerative changes
    • Secondary - associated w/ other shoulder pathology (trauma, overuse) 

    • Clinical Presentation:
    • → Empty end-feel (abduction = subacromial; ER = subcoracoid)
    • → Painful arc
    • → Non-capsular pattern
  37. Acromioclavicular Joint Injury
    Traumatic: fall on shoulder w/ arm adducted to side
  38. Grades of AC Joint Sprain
    1: Ligaments intact, (-) X-ray

    • 2: A-C ligament tear, intact or sprained C-C ligaments
    • →Clavicle unstable
    • →AC space seen on X-ray

    3: A-C and C-C ligament tear, downward displacement of acromion

    4: Similar to type II w/ posterior clavicle dislocation

    5, 6: Gross displacement of clavicle
  39. Sternoclavicular Injuries
    Traumatic: FOOSH (anterior dislocation more common than posterior)

    • I: Intact ligaments, stable joint
    • II: SC subluxation w/partial capsular and ligamentous disruption
    • III: SC ligaments and capsule completely disrupted w/ anterior or posterior dislocation
  40. Brachial Plexus
    • Stretch/compression of c-spine (Stinger or Burner Syndrome)
    • Burning or paresthesia throughout ambiguous dermatome distribution
    • Transient loss of ROM and muscle weakness
  41. Thoracic Outlet Syndrome: Definition and Mechansims
    Compression of neural or vascular structures passing through thoracic outlet

    • Mechanisms:
    • → Primary = cervical rib, clavicle, scalenes
    • → Secondary = postural variation
  42. Thoracic Outlet Syndrome Presentation
    • Numbness and tingling in hand
    • Decreased circulation or "falling asleep" sensation in UE w/ overhead motions
    • Pain in interscapular area, medial arm, forearm, hand
    • TTP over scalenes
    • Paresthesia w/ UE elevation
  43. Thoracic Outlet Syndrome: Clinical Tests
    • Allen
    • Adson

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Shoulder Pathology
2014-02-13 15:58:39
Shoulder Pathology
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