Kevin Carneiro, DO

SCI Shoulder Injuries

Outline

Shoulder function

Shoulder anatomy and kinematics

Shoulder function in SCI

Common shoulder pathologies

Rehabilitation and treatment of shoulder in SCI

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)

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

STABILITY MOBILITY

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

Shoulder

Complex

3 Joints

1 articulation

Which one has more stability?

Secondary stabilizers

Labrum and

Ligaments

Secondary stabilizers

Muscles

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

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

Scapulothoracic Stability

Coracoclavicular ligament & muscles

Scapulothoracic Mobility Observe medial inferior scapular border relative to spinous

processes

Elevation/Depression

Protraction/Retraction

Upward Rotation/Downward Rotation

Scapular movements

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

Supraspinatus

O: Suprasp. Fossa

I: Gr tuberosity

Abduction

Able to fully abduct shoulder

without supraspinatus

Infraspinatus & Teres Minor

O: Inferior scapula

I: Greater tuberosity

Ext Rot

Subscapularis

O: Costal scapula

I: Lesser Tuberosity

Int Rot

Ant Stabilizer in 45° abduction

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

Scapular retraction force couple

Middle and lower trapezius + rhomboids cooperate to retract the scapulo-thoracic joint

The dashed line indicates the net retraction force

Subscapularis: Infraspinatus Couple

Transverse Plane

In internal rotation,

infraspinatus provides and

equal and opposite F with

eccentric contraction

Keeps humerus on glenoid

Scapular Rotation Force Couples

Upward

Rotation

Upper

trap+

upper SA

Lower trap

+ lower SA

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

+ =

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”)

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

Kinetic Chain and Shoulder Motion

Contralateral bending

through the spine – higher

reach

Serrape effect: Contralateral

hip and shoulder are

connected through core

muscles

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

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

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.

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

Principles: What are the main

pain generators?

Glenohumeral joint capsule

Acromioclavicular joint

Biceps Tendon

Subdeltoid Bursae

Sternoclavicular joint

Referred pain

Rotator Cuff Injuries

Impingement

Tendinitis

Partial/ full tear

Tendon degeneration

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

Impingement

Most often affects:

Supraspinatus tendon

Subacromial Bursae

Biceps Tendon

Can get subdeltoid bursitis from accelerated throwing phase

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

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

Acromion Anatomical Variants Type III most associated with Impingement/RTC tears

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)

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

Rotator cuff terminology

Tendinitis: active inflammation.

Tendinosis: collagen degeneration, fiber necrosis, and

neovascularization.

Tendinopathy: any pathology/abnormality.

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

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.

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

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%

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

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.

Rotator Cuff Tear

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

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

Supraspinatus tear – MR arthrogram http://uwmsk.org:8080/UWR/stories/storyReader$41

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

Treatment

Re-evaluate in one year if not improving – may be

different etiology (early adhesive capsulitis)

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.

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.

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

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.

Instability

Anterior instability

Posterior instability

Multidirectional instability

Primary – Marfan’s, Ehler-Danlos

Secondary – repeat dislocations, hx trauma, chronic overuse

Spectrum Disclocation, Subluxation, Laxity

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.

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

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.

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

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.

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.

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

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)

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.

The Apprehension Test

Sulcus Sign

Load and Shift Test

Humeral Head Translation

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

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;

CT arthrogram of Hill-Sach’s (Broca) Deformity http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kellyus.shtml

Bankart lesion http://www.steadman-hawkins.com/shoulder3/diag.asp

Bankart lesion http://uwmsk.org:8080/UWR/stories/storyReader$409

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

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

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

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

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

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

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

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