The shoulder that won t get better.
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- Justina Taylor
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1 The shoulder that won t get better.
2 Shoulder Injuries Acute Chronic
3 Acute shoulder injuries Instability Labral pathology (SLAP lesions) Fractures (clavicle, scapula, humerus) A/C joint injuries Rotator cuff tears Tendon ruptures (biceps, pectoralis major)
4 Chronic shoulder injuries Impingement syndromes (including subacromial pathology) Labral pathology Laxity in the throwing athlete Rotator cuff pathology Referred pain Others (Zebras and normal horses)
5 Making sense of impingement Anatomical abnormalities (e.g. beaked acromion) Poor scapular control Anterior instability Excessive load on rotator cuff muscles Encroachment from above Inferior movement of acromion Anterosuperior translation of humeral head Rotator cuff weakness Impingement with exercise Narrowing of subacromial space Rotator cuff tendinitis Swelling of rotator cuff tendon Imbalance between humeral head elevators and depressors Elevation of humeral head Instability Overuse Abnormal biomechanics Posterior capsule tightness
6 Making sense of impingement
7 If the impingement won t get better. Anatomical encroachment from above
8 If the impingement won t get better. Scapular stability
9 Causes of poor scapulothoracic rhythm Long thoracic nerve palsy Brachial plexopathies
10 If the impingement won t get better. Anterior humeral translation Think about posterior capsular tightness
11 Capsular restrictions End stage frozen shoulder Aetiology uncertain Associated with diabetes, heart disease Females more common Night ache
12 Capsular restrictions Sporting population usually subtle and minimal Night ache Pain with end range activities
13 Capsular restrictions Decreased range of motion - especially end abduction, internal rotation and horizontal flexion Relocation test positive AP glide sensitive
14 Capsular restrictions treatment Don t like being mobilised Corticosteroid injection Hydrodilatation If all else fails.arthroscopic capsular release
15 Capsular restrictions Still need best practice rehabilitation after hydrodilatation or arthroscopic treatment
16 If the impingement won t get better. Rotator cuff function (Remember rotator cuff tears)
17 Rotator cuff dysfunction suprascapular nerve entrapment Anatomy
18 Suprascapular nerve entrapment Chronic rotator cuff weakness often presents as an impingement Sometimes exercise induced pain Common in volleyball
19 Suprascapular nerve entrapment treatment Conservative -massage - Neuromeningeal - Cervical spine
20 Suprascapular nerve entrapment treatment surgery
21 Bony pathology Osteolysis Stress fractures others
22 Osteolysis distal clavicle Common in weightlifters (bench press) Chronic A/C joint pain Tender distal clavicle Increased uptake on bone scan
23 Osteolysis distal clavicle treatment Physiotherapy Corticosteroid injection surgery
24 Stress Fractures Coracoid process (trap shooters)
25 Stress Fractures 1st rib in ballet dancers o o o o o Pain hard to localise Often thoracic or chest pain Pain with coughing and sneezing Local tenderness over 1st rib Pain with AP pressure centrally
26 1st rib stress fracture investigations X-ray Bone scan
27 1st rib stress fracture Technical issue in dancers Related to anatomy Usually settle with rest (4-6 weeks)
28 Other bony pathology Tumours
29 Osteoid osteoma Young footballer elite Six month history of shoulder pain Night/rest ache Helped by aspirin Bone scan hot CT scan Pain relieved by excision
30 Psoas Very cool muscle Anatomy well known Intimately related to diaphragm
31 Psoas Vague shoulder pain Positive femoral slump (with added ULTT) Responds to manual psoas release
32 Psoas Treat with psoas sheath injection Why does it work?
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