Shoulder And Arm

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Anatomy of Shoulder and Arm

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Anatomy•

The shoulder is made up of 4 joints; the glenohumeral,acromioclavicular, sternoclavicular and scapulothoracic• Ligaments, joint complex, muscles, tendons and fascia all stabilise thejoints• There are force couple groups of muscle which works work togetherto generates movements, eg. rotator cuff muscles pull glenoid head in asdeltoids abduct

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(Shoulder and arm)

Common presenting complaints

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Painful Arc ​- Anterior shoulder pain ​- Top of the shoulder girdle pain ​- Pain deltoid insertion ​- Pain at end ROM ​- Age dependent

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TendonOveruse Injuries:

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Transmits force from muscle to bone, has anincreased resistance to strong tensile forces but a decreased resistance tosheering force and a very low resistance to compression. Vasculature is variable, generally vasculartendons are surrounded by paratendon and avascular by sheaths, these can becompromised by friction, torsion or compression.They usually respond to an overload byinflammation of the sheath and degeneration or tears of the body.

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Tendinosis/Tendonopathy:

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. Collagen disarray and separation

· It is generally painful at restand initially with exercise but decreases as you warm up and returns once cool.

. During healing there is localtenderness and thickening.

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Impingement:

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History of painful arccomplaints on orthopaedic assessment e.g. empty can, Hawkins Kennedy, Neersetc. (depending on which tendon is affected)·

Supraspinatus is the mostcommon.

There are three stages ofpathology associated with impingement.

Treat the same as you would fora tendonopathy and manage the injury by taking away the causative factors.

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SubacromialBursitis:

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Is due to the perpetuate degeneration ofthe rotator cuff, it can be the result of an ongoing tendonopathy and is oftenrelated to calcific migration. Contraindication- infectious bursitis

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SLAPLesion/Labrum:

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The labrum deepens the glenohumeral jointwhere the biceps tendon attaches, allowing the head of the humerus to sit inthe socket provided by the scapula better resulting in increased stability,with overuse the labrum can degenerate causing the joint to be less stable.

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SLAP Lesion/Labrum Class:

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· Type 1. Slight degeneration, 2.3. 4. Labrum is torn from the bone creating a flap, vertical or Bankart lesion.·

Mechanism of injury- acute ofchronic is nature due to traction or compressive forces with overhead, FOOSH,carry, drop and catch, dislocation and subluxation injuries.

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BicepsTendonopathy Anatomy:

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Long head- attaches to thecapsule and radius·

Short head- attaches to thecoracoid process and radius·

The tendons are held into thebicipital groove by the transverse ligament.

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BicepsTendonopathy:

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Injury to these affects the upper limbsability to flex and supinate the arm, tendonpathy can be due to degeneration inthese regions, impingement of the biceps tendon causing trauma, overuse,ischemia, transverse ligament laxity (allowing for too much movement andpotential friction of the biceps) or a tear.

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AdhesiveCapsulitis:

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Usually occurs in the non-dominant arm, itis more common in females and there are increased chances between the ages of40-60 years as well as increased chances if the patient has a sedentarylifestyle.

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Adhesive Capsulitis Stages:

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1.Mild synovitis, pain at the endof ROM

2. Adhesive synovitis, pain andstiffness at night/rest

3. Frozen shoulder, extremelypainful, ROM is very restricted

4. Resolution, although generallythe issue is never fully resolved

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ShoulderDislocation:

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Synovial ball and socket joint is shallowand the glenohumeral joint stability depends on the shape and size of the tilt.Ligaments act as static stabilizers and muscles as dynamic. It is important toregain their function after an injury as they control whether or not movementis normal or abnormal, balance of force couples is also important, if this islost the shoulder is more prone to dislocation. Females and teenagers have increased laxityand are therefore more likely to suffer from a dislocation, the younger thepatient is when there first dislocation is the more likely it is to reoccur.

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Shoulder Dislocation Classifications:

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1. Acute/traumatic- forcefulmovement occurs, patient is caught off guard

2. Occulta- subluxation developed inyoung athletes who compete frequent, forceful overhead movements. Often thereis a sensation of weakness, parasthesia and pain during activity.3. Recurrence- abnormal laxity,muscle weakness, excessive stretching or inadequate rehab.

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Shoulder Dislocation Types :

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1. Subclavicular

2. Subcoracoid

3. Subglenoid

4. Posterior

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Shoulder Dislocation Function and Pathology:

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90% of dislocations are anterior inferior the mechanism of injury isusually abduction, external rotation and extension.

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Shoulder DislocationAssessment:

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Observation- landmarks such as Calloway’ssign and Hamilton’s ruler testing, inferior/anterior shoulder, one hand lowerthen the other etc. Neurovascular- sensory, dermatome andreflex testing Static and motion palpation, ROM,Orthopaedic testingDiagnostic imaging- an x-ray will show aHill-sachs lesion and an ultrasound will show a Bankhart’s lesion, as well asany muscular lesions in the rotator cuff.

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Acute anterior and not self relocated injury Treatment

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treat with ice, sling, dx imaging,relocation. This is dependent on the situation, often more damage can occurduring relocation, if it goes back in gently and easily its generally okay,also if it is reoccurring/have had multiple dislocations they often wait untilmuscle spasm etc. are over and then self relocate.

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Acute Posterior Treatment-

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treat with ice, sling, referral. Never attempt to relocate thisdislocation

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Acute and self relocated Treatment

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treat as a grade 2/3 sprain or strain

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Chronic pain and d/t dislocation Treatment

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Treat as a chronic grade 2/3/ sprain or strain, this is difficult asthere will be a lot of tissue damaged and it is often very unstable, make sureyou treat associated damage.

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Acute Shoulder dislocation Treatment

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Immobilisation; PRICES- is good forligamentous and capsular healing but can be detrimental to muscle healing andcan cause atrophy of the deltoid within 72hrsMobilisation (MAT/manual) > AdjustmentsMotion exercise- it is important to getnormal range of motion early on as well as some proprioception exercises Anti-inflammatories and nutritionTapingCross-friction (?) and muscle balance- dealwith post damage dyskinesia Advice- dependent on the patient

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Chronic Shoulder dislocation Treatment

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Goals: stability and alignment, normalrange of motion and strengthEnsure proper functionSoft tissueExercise- gym based can be better thanswimming which can often exacerbate certain conditions· Stimpson technique: for ananterior shoulder dislocation. Have patient lying supine on table. Get pastsplinting reaction- mechanism of the body to contract muscles to protect joint.

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Shoulder Instability

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Common cause of shoulder painRecurrent/transient- trauma, overuse,hypermobility Check for hills-sach and bankart lesions-these could be causing/contributing to the instability

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Shoulder Instability Types:

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Medical Subluxation- partial dislocation,incorrect juxtapositionDislocation

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Shoulder Instability Treatment

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Progressive strength exerciseNOT at the end of range of motionReferral for surgery

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A/CJoint Injury:

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Common in martial arts, FOOSH injury,falling on tip of shouldershoulder/hitting shoulder.

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A/C Joint Injury Morphologyand Function:

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Minor tear of capsule with disc irritationTear of capsule and disc·

Grade 1- small step defect,swollen, painful. Like a sprain or superior subluxation, can often adjust. Canstart with progressive exercise · Grade 2- step defect, swollen,painful. Can adjust but follow up by taping so it doesn’t pop back (2-4 weeks)·

Grade 3- step defect, can causepainful arc problems due to associated structures. Taping or bracing to holdclavicle down and hold the associated tissues. (4-6 weeks) Can refer patientsfor surgery.

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A/C Osteoarthritis:

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In women with diabetes who are >20 yearsold will start to see DJD of the meniscus. Subchondral sclerosis, cysts,osteophytes, joint DJDTraumatic osteolysis- clavicle begins tobreak down and lose mineralization

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A/C Osteoarthritis History

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Gradual onsetHurts when starting movement, goes way andcomes back if too much movementCrepitus and decreased ROM

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A/C OsteoarthritisTreatment:

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· Heat

· Exercise- often whole body,progressive

· Mobilisations and adjustments,MAT or modified

· Advice

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S/CSprain or dislocation:

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Dislocations are relatively rare (1/3) butsprains are common- often injured by the seatbelt in car accidents (theopposite side to the belt generally)

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S/C Sprain or dislocation Grades:

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· Grade 1- pain, swelling,changes in joint play

· Grade 2- associated ligamentsdamaged, damage to meniscus

· Grade 3- neurovascularcompromise, pressure on trachea can be dangerous, anterior is more common

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S/CSprain or dislocation Treatment

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Anterior- Adjust for grade 1 or 2 (lowforce>high force). For a dislocation you do a covered thumb adjustment withsomeone else pulling patients arm. You can tape or brace into post adjustmentposition to let it set.

Posterior= medical emergency, hospital- dueto neurovascular compromises etc.Ensure proper function of spine andshoulder girdle- this takes stress of the AC joint

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HumeralFractures Morphology,Function, Pathology:

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· *Osteoporosis (or otherpathology)· Pain and muscle splinting

· Associated dislocation

· Neurovascular injury

*Osteoporotic fractures- in older people

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Humeral Fractures History

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FOOSH- neck of humerus is commonAdolescent- epiphyseal injuryTrauma- falling is generally shaft injury

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Humeral Fractures Assessment:

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· Neurovascular testing- makessure there is no compromise, generally radial

· Decreased ROM

· Muscle splinting

· Diagnostic imaging such asx-ray etc.

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Humeral Fractures Treatment:

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Acute- referral for medical assessment,setting, casting, slingSub acute/chronic- Healing andrehabilitation

· Magnetic therapy

· Nutritional supplementatione.g. calcium, manesium, zinc

· ROM Exercise

· Mobilisation or modifiedadjustment and spinal adjustments

· Once healing has occurred theaim is to return function

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ClavicleFracture:

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If there is enough force to fracture theclavicle there may be enough force to fracture the scapula.Children and adolescents are more prone togetting incomplete fracturesAdults tend to get complete fracturesIt can be a complication at birth.It affects the tissue underneath theclavicle, often nerves of the brachial plexus and can commonly cause thoracicoutlet syndrome

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Clavicle Fracture Morphology and Function

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· Type is usually dependent onfactors such as age

· Impact is absorbed at theweakest point in the bone

· Can be due to complications atbirth

· Compromised circulation andnerve supply can occur, this is usually of the medial branch

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ClavicleFractureAssessment :

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Position of trauma- holds elbowand shoulder droops down, often displacement (sometimes this is seen with A/Cjoint dislocation but more common with this injury)

·Asses for neurovascularcompromise- test ulnar nerve

· If pain is persistent think ofthe scapula?· Neonate differentials

· Diagnostic imaging/X-ray (beaware of distal 1/3)

· If pain is persistent andcontinuous- it could indicate damage to surrounding structures

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Clavicle Fracture Treatment

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(6-8 weeks)Stiffness is common afterwards- STT,general adjustments on joint, scapula and spine.

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Sprengles Deformity

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Congenital- rare congenital skeletalabnormality where a person has one shoulder blade that sits higher on theirback than the other. It is due to a failure in early fetal development, wherethe shoulder fails to descend to its required position properly from the neck.It’s often associated with other conditions such as Klippel-feil syndrome(abnormal fusion of cervical vertebra),congenital scoliosis, cervical scoliosis, fused ribs, omovertebral bone, spinabifida etc. Generally it is the left shoulder that is affected, but can be bilateral.75% of cases are girls

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Sprengles Deformity

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Paralyses of the serratus anterior muscle(from birth)- generally from damage to long thoracic nerve during birth- nostability to hold scapula up to rib cage. Sometimes damage can also occur fromother accidents that may affect the brachial plexus

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Sprengles Deformity

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· Usually unilateral ·

Major component is the posturalchange

· Full ROM is not possible

· Congenital- surgery generallybetween 4-7 years

· Acquired- cycling andmotorcycle injuries are commonly associated

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Sprengles Deformity Treatment

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In early childhood this consists of surgeryand physical therapy, surgical treatment is adults is complicated by the riskof nerve damage when removing bone and during relocation due to stretching ofmuscles and surrounding tissue- so treat as if it was a suprascapula entrapment

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Brachial Plexus Injury

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When you have a brachial plexus injuryshould you refer straight away- if fully torn you can’t do much, but if itsjust an over stretch injury then you can have an influence on the patientstreatment, if there is damage where the patient is left with deficit then youshould refer. Electromyograms, conduction studies- refers for.

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Brachial Plexus Injury Morphologyand Function:

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· Level- nerve root, trunk,division, cord or peripheral nerve· Type of trauma- compression ortraction (slipped while holding onto something), childbirth· Can result in ERB’s palsy (paralysis of arm due to severed C5-6),Klumpke’s paralysis (injury to C8,T1 of baby during birth)

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Brachial Plexus Injury Assessment

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Waiter’s tip or claw hand(etc.) type posture· Neurological assessment- muscletesting, dermatomes and reflexes· EMG· If atrophy starts to occurafter traction or compression injuries refer for other testing such asdiagnostic imaging (the faster the better, time)- sometimes better of payingfor it then claiming it back on work cover than waiting for the cover.

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Brachial Plexus Injury Treatment

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In acute cases use ASPENRAC and modify with MAT, once atrophy occurstherefore in a more chronic case referral for surgery could be the best option.

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Brachial Plexus Neuritis Morphology, Function, Pathology

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Infectious or inflammatoryRelated to other systemic disorders-arthritisAxillary, suprascapula and long thoracicnerve interference

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Brachial Plexus Neuritis Assessment:

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Rapid onset of pain with no history of trauma- generally unilateral followed by weakness and paresis (muscle and nerve testing) even fasciculation’s in severe cases- write a good background so you can make referrals Laboratory testing will determine whether or not it is an infectious cause- presence of inflammatory or infection markers in the blood etc. If atrophy starts to occur after traction or compression injuries refer for other testing such as diagnostic imaging (the faster the better, time)- sometimes better of paying for it then claiming it back on work cover than waiting for the cover.

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Brachial Plexus Neuritis Treatment

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In acute cases use ASPENRAC and modify withMAT, treat systemic disorder or infection (can use medication e.g. antibiotics)/usea multimodal approach. Be careful you can also stay away from the area untilcompression/inflammation etc. calms down. If adjusting set the patient up firstto see if it’s going to irritate the tissues or make injury worse. Try andrestore function, and healing will occur.Nutrition, advice, general healthimprovements should help.

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Shoulder-Hand-Finger Syndrome

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Type 1: Most commonly seen in practice.Sometimes from an injury, single peripheral nerve involvement (sometimes),there are physiological changes in the affected limb- hair loss etc. changes tothe sympathetic nervous system. Spontaneous pain, swelling, different skintemperature, progressive and bone atrophy and tissue loss.

Type 2: Less common.

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Shoulder-Hand-Finger Syndrome Function

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Vasodilation and stiffness, atrophy, pain, increased sympatheticactivity, changes to the circulatory pump.

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Shoulder-Hand-Finger Syndrome Mechanism

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Initial injury > Pain triggers sympathetic nervous system >Triggers inflammation> Pain, throbbing, temperature, burning and redness> stiffness, hair loss etc. > Atrophy, tissue/bone loss

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Shoulder-Hand-Finger Syndrome History

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· Type “A” personality-tightlystrung· Symptoms as a result of trauma· Continuous burning or throbbingpain, usually in the arm, leg, hand or foot· Sensitivity to touch and cold· Swelling of the painful area· Change in skin temperature andsweat· Change in skin colour rangingfrom white to mottled to red to blue· Changes in skin texture e.g.thin, tender or shiny· Changes in hair and nail growth· Muscle spasms, weakness andloss· Joint stiffness and swelling· Decreased movement

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Shoulder-Hand-Finger Syndrome Assessment:

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Changes in:

ROM, palpation, neurological sensitivity,skin, nails, hair, joints, muscles. Can perform bone scans- shows differencesin blood blow and bone density, thermo scans can also be helpful.

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Shoulder-Hand-Finger Syndrome Treatment

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· ASPENRAC· Don’t overdo adjustments orheavy soft tissue· Nutrition, personal training· Self-management- patients needto change there lifestyle e.g. things such as bedtime, exercise, diet,meditation, heat and ice, taping, bracing etc. · Monitor changes closely · Medical approach- medicalblocks (sympathetic nerve blocks), surgical intervention medications e.g.NSAIDS, neurostimulation of the spine or nerves· Psychological- counseling,relaxation, coping skills, behavior, motivations etc.