Shoulder Pathology and Physical Examination

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Shoulder Biomechanics

Shoulder Imaging

• X-Ray– A.P. view– Coned A.P. view (internal and external rotation)– Axial view– Outlet– A.C joint– Scapulothoracic– Sternoclavicular

A.P. view (true)

Anterior posterior view

•

Axilliary View of the Shoulder

Scapula Outlet view

Acromial shapes

Acromial Morphology

• Type 1 17%• Type 2 43%• Type 3 40% - associated with a higher

incidence of rotator cuff tears

• Acromion Types• Type I: Flat, smooth acromion at clavicular

joint – Normal subacromial space

• Type II: Hooked acromion – Subacromial space mildly decreased

• Type III: Hooked acromion with spur – Subacromial space significantly decreased

Ultrasound• Operator dependent• Variable sensitivity • Inexpensive• Non-invasive no irradiation (is MRI completely

safe?)• Allows dynamic imaging• Requires best equipment• Full thickness tear extends from the articular

surface to the bursae• “white is right unless it is calcium”

Ultrasound continued• High specificity for all cuff and biceps tears

94 -100%• High sensitivity for full thickness tears 90 -

100%• Moderate sensitivity for partial thickness

tears 46-86%• Moderate sensitivity for biceps tendon

rupture of tendinitis (75-80%)• Not sensitive for labral tears

Possible Pathologies– Musculotendinous Injury

• Acute tendinitis, tendiosis, tendinipathy, calcific tendinitis • Musculotendinous tear• Biceps tendon rupture, Pectoralis major rupture

– Subacromial Bursitis– Impinnement syndrome– Frozen Shoulder– Osteoarthritis of GH joint– Osteoarthritis, instability, osteolysis of the AC joint– Ligament injuries – A.C. joint and GH joint– Chronic Instability– Labral injuries– Fractures– Osteolysis– Cervical referral

• Somatic• Neural

– Nerve injury• Long thoracic, axilliary , suprascapular, brachial plexus

– Malignant disease– Cardiac– Mediastinal– Inflammatory arthropathies

• Rheumatoid arthritis, ankylosing spondylitis, post viral arthritis

Impingement Syndrome• Neer (1981) - painful compression of subacromial

structures, primarily the supraspinatus and biceps tendon underneath the anterior one third of the acromium

• Also posterior impingement, subcoracoid impingement, • Factors that can predispose these structures to

becoming painful• Trauma eg fall, heavy lift, repetitive activity• Factors associated with increased risk of Microtrauma

– Subacromial space stenosis (1.1cm between acromium and humeral head at rest)

– Altered scapular mechanics (18 % of normals, 64% unstables, 100% of impingers)

– Poor Spinal posture– hypertrophy of subacromial structures (supraspinatus

tendon, long head of biceps tendon, bursae, coracoacromial ligament)

Impingement• Pain at night, pain with overhead activities,

painful arc all indicate a subacromial pain generator

• Still unclear– Does impingement lead to cuff

degeneration or does cuff degeneration lead to impingement

– Absence of inflammatory cells in teninosis, also it is often asymptomatic

Adhesive Capsulitis (Frozen Shoulder)

Long head of biceps rupture

Pectoralis Major Rupture

Acromioclavicular Joint

• Trauma, Arthropathy, Osteolysis of distal end of clavicle

Acromioclavicular Joint Sprain

Winged Scapula from Long Thoracic Nerve Palsy – Post viral or Post

traumatic

Examination of the Shoulder– Observation - Wasting, deformity, muscle bulk– Palpation – AC joint, biceps tendon, clavicle,

infraspinatus, supraspinatus– Neck/Shoulder Differentiation

• Active movements, palpation, pain location– Active - flexion, abduction, HBB, Ext. rotation in 0, 90,

HBH (from front and behind)– Functional Testing. N.B. Impingement can carry and pull – Impingement tests

• Neer’s test • Hawkin’s Kennedy test (1980)

– Resisted • ER, IR, Liftoff, Long head biceps, Short head of biceps,

Supraspinatus (Jobe etal 1982, Kelly 1996)– Passive- Flexion, abduction, External rotation in neutral

and abduction, – Acromioclavicular tests – compression, distraction

• Positive Hawkins Kennedy– Sensitivity 92%– Specificity 25-44%

• Positive Neer Impingement– Sensitivity 75% -89%– Specificity 31%-48%

Other Tests• Labral tests

– Modest sensitivity and specificity– Anterior slide test– Empty can test– Crank test– MR with arthrography is best as normal MR is often

insufficient• Stability Tests

– Anterior Drawer– Relocation– Apprehension– Sulcus test

• Neurovascular Tests• Tests for muscle length and strength

Other

• Treatment for frozen shoulder– Distension arthrography– Surgical release of capsule– MUA– MUA plus physiotherapy– Depends on phase with Physiotherapy very

limited early on

Evidence for Physiotherapy and Shoulder Pain

• Rotator cuff tears – no trials• Tendinopathy – no trials• Calcific tendinitis - Ultrasound has been shown to relieve

pain and disability and reduce the size of calcification with calcific tendinitis (Ebenbilcher 1999)

• Adhesive capsulitis – no evidence (5 trials)• Adhesive capsulitis with cortisone and physiotherapy -1

trial• Osteoarthritis – no trials• Impingement Syndrome

– Exercise demonstrated to be equally as effective as arthroscopic decompression (Brox. J. et al., 1998; Rahme, H., et al., 1998)

Physical Therapy Management

• Removal of risk factors• Correction of scapular mechanics• Rotator cuff strengthening• Postural correction• Stretching of tight structures