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SHOULDER DISEASES

Impingement Syndrome
Supraspinatus Tendinitis
Bicipital Tendinitis
Adhesive Capsulitis
Calcific Tendinitis
Shoulder Dislocation
Hemiplegic Shoulder
Fracture of AC Joint
Reflex Sympathetic Dystrophy


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IMPINGEMENT SYNDROME

     -Aka Painful arc syndrome 
     –a certain arch of mov’t or ROM the process of compression appears;
        bet. 60 – 120 degrees of flexion and abduction
     -Aka Subacromial syndrome 
     –the process of compression appears below the acromion.
     -Aka Supraspinatus syndrome
     -There is a structure that is being compressed and
        that is the Rotator Cuff.

  * Rotator cuff muscles – originate from the scapula;
         insert to the humerus some to the greater tuberosity and some
         into the lesser tub.
  * Supraspinatus – occupies the most superior, most
         lateral and most superficial part of the shoulder.

     - Most of the shoulder activity requires abduction and
         internal rotation and these mov’t will cause impingement
         bet the structures.
     - Configuration of acromion has something to do with
         the impingement syndrome.

     3 types of acromion  

     Type 1 -  flat 
     Type 2 – smooth curve
     Type 3 – angled (hook) curve; most common rotator cuff tear;
                     no abduction anymore

     -Coracoacromial arch – made up by the acromion and coracoacromial lig.

     Differential diagnosis:

      1.  Adhesive capsulitis
      2.  Calcific tendinitis
      3.  Crystalline and rheumatoid arthropathies
      4.  Cervical neuropathy
      5.  Dynamic functional instability
      6.  GH joint degenerative disease
      7.  Tumor of the shoulder girdle and lung apex

     Classification of impingement syndrome:

	     Primary				secondary
     Aqua stenotic			aka non-stenotic
     Aka extrinsic instability	        aka intrinsic instability
     There is compression	        there is an instability producing
     Young (laborer, athletic)	                      compression
     Repetitive overhead activity	elderly (uncoordinated ms.)
     Abd-prox migration of the
	Humeral head
     95% of rotator is due to 1°

   * Tendinous portions of supraspinatus tendon and
         rotator cuff have an area of vascularity
   * Critical zone – localized area of vascularity located in the ˝ proximal
         to the point of insertion and this area of hypoperfusion, ischemia
         and degeneration.
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SUPRASPINATUS TENDINITIS

   -Occupies the outermost portion of the RC ms.
   -Most frequent cause of shoulder pain.
   -Common in young ones bec. Of repetitive activity
   -35 – 50 y/o 
   -Women > men
   -Initially there is a deep pain in the shoulder, localized anteriorly but
        can radiate to the deltoid insertion and anterolateral aspect of the
        upper arm.
   -Pain with shoulder elevation and is not accompanied by LOM (initially),
        but later on it will be followed by LOM and stiffness.
   -60-120 degrees – range where pain occurs

   * Impingement sign – ask the px to have a thumbs down position,
        medial aspect of the palm is under the chin. PT stabilizes the
          scapula and lifts the flexed elbow. If more pain is added, there
          is an additional evidence for impingement syndrome.
 
   * Impingement test – inject lidocaine that is anesthetic to the
        subacromial bursa or under the acromion. Repeat the procedure
        of the impingement sign. If pain disappears it has (+) result.

     Clinical stages:

   Stage I
   - px complain of pain that is deep and toothache like in the ant.
   Shoulder.
   - Aggravated by flexion and abduction of the arm (overhead activity)
   - More severe at night bec inflammation accumulates
   - There is tenderness in the acromion.
   - Mx can reverse the condition.

   Stage II
   - more severe pain
   - Beginning to have LOM
   - Px complains of catching sensation when the arm is brought
        down from abducted position.

   Stage III
   - tearing of rotator cuff
   - LOM and weakness
 
   Stages based on the MRI findings: (near classification)

   Stage I   - rotator cuff has inflammation, edema and hemorrhage = PAIN
   Stage II  - tendonitis + fibrosis = more severe pain and LOM
   Stage III  - partial or complete tendon tear = WEAKNESS
          - If < 1 cm = 3a
          - If > 1 cm = 3b
   Stage IV- multiple tendon tears
 
   Complete rotator cuff tear findings:
     1.  Weakness in shoulder abduction and ER
     2.  PROM > AROM
     3.  Atrophy of the supraspinatus and infraspinatus
     4.  Crepitus
     5.  (+) Drop arm test
     6.  Accompanied by pain and tenderness in the AC jt.

   -Tx: initial – avoid motions. NSAID’s, thermal agents (superficial
          followed by deep)
   -Tx: severe pain – inject steroids with anesthesia to have rapid
   improvement. Once pain is relief and inflammation subsides
   start stretching (gravity assisted codman’s ex) and
   strengthening (dynamic stabilizers of the shoulder – SITS and
   long head of the biceps; scapula – rhomboids, trapz, serratus
   anterior)
   
   -Surgery – removal of spurs, anterior acromioplasty, release of
        coracoacromial lig, repair of rotator cuff tendon
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BICIPITAL TENDINITIS


-  Common in elderly
-  Due to frequent overhead activity
-  Long head is stretch during cocking stage
-  Concomitant component findings for stage II and III
-  Inflammation of the tendon as it passes through the
     bicipital groove or intertubercular groove.

Risk factor:
  1. Shallow groove
  2. Abnormal rigid in groove
  3. Overuse of muscles
  4.  Secondary to trauma to bicipital groove
  5.  Secondary to inflammation

  Manifestation:
  1.  Anterior shoulder pain radiating laterally
  2.  Pain on elevation and abduction motions
  3.  Severe pain at night

-  Special test: yergasons and speed test
-  (+) Impingement test
-  Mx: same as rotator cuff tear; can also use cold therapy
     for inflammation; thermal heat moist heat then deep heat
-  To prevent recurrence – maintain normal GH jt and scapulothoracic
     motion to the dynamic stabilizers of the scapula
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ADHESIVE CAPSULITIS

  -  Aka frozen shoulder
  -  Aka periarthritis
  -  Aka obliterative bursitis
  -  Aka diffuse rotator cuff tendinitis
  -  Common chronic affectation characterized by pain and limitation of
       shoulder motion that slowly become worse over a period of 3-12
       months then follows a course of gradual improvement to a normal
       to near normal state.

  Risk factor:
  -  > 40 y/o
  -  Common in women > men
  -  DM
  -  Thyroid disease
  -  Lesion on shoulder
  -  Personality disorder (periarthritic personality)
  -  Prolonged immobilization

  3 stages:
  1.  Pain
  2.  Progressive stiffness
  3.  Gradual recovery

  - Tx:
  1.  NSAID’s
  2.  More invasive tx – saline solution + 40 cc H2O injected to distended
         adhesive + movement = brisement maneuver
  3.  Sling – arm abducted and ER
  4.  Pendulum exercise
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CALCIFIC TENDINITIS

  -  In its severe form are the most painful benign affectations to which
         humans are subject.
  -  Supraspinatus tendinitis + calcium deposition
  -  Calcium deposit to an area if there is an excessive swelling and
         bleeding.
  -  ETIOLOGY: unknown
  -  Young
  -  During calcification: pain is very mild
  -  During calcium resorption: pain is severe
  -  Site of deposition: critical zone
         (1 cm – 1 inch fm greater tuberosity)
  -  (+) Impingement test
  -  X-ray: use to differentiate it to other conditions
  -  Tx: aspirate calcium and boost steroids
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SHOULDER DISLOCATION

  -  Young px; < 20 y/o
  -  (+) Sulcus sign
  -  Acute
  1.  Sig trauma: rounded portion of shoulder is absent (denervated deltoid)
  2.  Palpable of visual space, sulcus between acromion head
  3.  LOM
  4.  X-ray – post axillary view can be done
  5.  Tx: -close reduction
  - Sling or splint for adduction and IR (young – 6 wks)
  - Isometric exercise to prevent atrophy for few days
  - Active exercise w/o ER and abd up to 90 degrees for 6 wks (old – 2-3 wks
       to prevent frozen shoulder
  - 1st 2-3 days: isometric
  - 2-3 wks: active exercise
	
  Indication for surgery:
  1.  Fracture
  2.  Accompanied by rotator cuff tear
  3.  Neurovascular injury (nerve or blood vessels)
  4.  Severe osteoporosis

  Recurrent:
  1.  Minor trauma, less force, normal mov’t
  2.  Shoulder instability: previous acute traumatic dislocation
  3.  Cause:
  - Overstretching of the lig.
  - Increase healing of the shoulder structure and glenoid labrum
  - Weakness of shoulder muscles
  - Acquired congenital abnormal in humeral head and glenoid fossa

  Diagnosis (instability)
    1.  Hx of trauma
    2.  Recurrent dislocation
    3.  Chronic overuse
    4.  Multiple jt instability
    5.  Severe palsies
    6.  Radiculopathies
    7.  Glenohumeral fx
     -  Suffered from acute traumatic dislocation
     -  95 % traumatic dislocation is ant (humeral head goes forward)
     -  Anterior portion of the shoulder is weak

  Types:
  1.  Subcoracoid – common anterior dislocation; there must be a force
         coming from ant resulting abd and ER; loss of normal roundness of
         shoulder; prominent acromion
  2.  Subglenoid
  3.  Subclavicular
  4.  Subspinous – very rare; post dislocation; humeral head is behind
         scapula; force from front, arm flex and adducted; prominent
         coracoid.

  -  Foramen of weitbrecht – common site of dislocation
  -  Glenoid labrum 	- fibrocartilage that deepens the glenoid fossa
  -  Chief important factor in shoulder instability
  -  Instability – laxity of static stabilizer
  1.  GH lig
  2.  Glenoid labrum
  
  * Instability – excessive translation of humeral head on the glenoid
       and subsequent labral diseases.

  Special test:
  1.  Lachman’s test – supine, shoulder is in the edge of table, abd 90, ER,
         elbow flex 90, support on the armpit, apply ant/forward thrust
         on shoulder
  2.  Relocation test

  Complication for relocation-dislocation:
    1.  Brachial plexus injury
    2.  Axillary nerve and blood vessels
    3.  Humeral fracture
    4.  Rotator cuff injuries

  -  Tx: close reduction

  RECCURENT SHOULDER DISLOCATION
  -  > 20 y/o
  -  Active lifestyle
  -  Abduction and ER mov’t of dislocation
  -  If repetitive: patient itself can reduce dislocation by opposing the
       direction of dislocation.
  -  Complication: arthritis
  -  Tx: surgery
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HEMIPLEGIC SHOULDER

  -  Seen in stroke px
  -  Concomitant finding: presence of anteropostero subluxation
  -  1st wk associated with spasticity
  -  Weak deltoid and supraspinatus muscles
  -  Dislocation: common in patient with flaccidity
  -  ETIOLOGY: multifactorial

  Underlying problems:
    1.  RC tendinitis
    2.  Bicipital tendonitis
    3.  Shoulder capsule contracture
    4.  Anterior inferior subluxation
    5.  RSD presence of ganglia
    6.  Suprascapular neuropathy

  Contributing factors:
    1.  Rotator cuff and biceps tendon disease
    2.  Anterior inferior subluxation
    3.  Spasticity
    4.  Capsular constriction
    5.  Suprascapular neuropathy

  -  Tx: prevent underlying problem, spasticity; support shoulder
       (sling, splint) on wheelchair with arm support.

  Drugs to reduce spasticity:
  1.  Baclofen – agonist of GABA
  2.  Dantroline – inhibits release of Ca in the sarcoplasmic reticulum
  3.  Diazepam – agonist of GABA A
  4.  Phenol - for motor point
  5.  Epinisone
  6.  Tizamidine

  -  GABA – gamma amino butyric acid; inhibits sympathetic transmission from
       nervous system
  -  Icing, stretching, PNF, vibration, ES, Reflex inhibitory
  -  Codman’s ex, steroid injection to decrease inflammation and adhesion
  -  Infiltrate saline solution up to the point of rupture of capsule
  -  Distention arthrograhy – infiltration brisement maneuver
  -  Manipulation under anesthesia, splint shoulder to abduction before
       weeks ER
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FRACTURE OF AC JOINT

  -  Fall on the lateral side; AC joint dislocate
  -  Crepitation across midline
  -  Apply pressure (if crepitus-arthritis)
  -  AC dislocation does not produce functional limitation
       but could later on cause RA

  Test:
  -  Move shoulder across chest or push up (+) if there pain

  Tx:
   1.  Manage pain and inflammation
   2.  Surgery (cosmetic purposes)
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REFLEX SYMPATHETIC DYSTROPHY
  -  Aka transient osteoporosis
  -  Aka post traumatic neuralgia
  -  Post traumatic dystrophy
  -  Aka sudeck’s atrophy
  -  Shoulder hand syndrome (shoulder and hand are painful and stiff)
  -  Most important underlying factor: inactive limb or dependent limb was
       impaired venous and lymphatic flow
  -  Chronic pain condition secondary to neurovascular disturbance resulting
       in trophic changes on skin and bone resulting to sympathetic
       overactivity.
  -  Disuse + sympathetic hyperactivity = TROPHIC CHANGES
  -  May follow trauma
  -  Fracture
  -  Strain
  -  Sprain
  -  Dislocation
  -  Surgery
  -  Hip replacement
  -  Close/open reduction
  -  Carpal tunnel release
  -  Medical conditions such as: MI, stroke, MS, tumor, radiculopathy

  Trophic changes:
    1.  Thinning and dying of the skin
    2.  Decrease growth of hair and nails
    3.  Atrophy of the skin and subcutaneous tissue
    4.  Osteoporosis

  Clinical stages:

  Stage I - ACUTE (3-6 months)
    	  - Pitting edema
	  - Swelling
	  - Warmth
	  - Pain
	  - Hyperhydrosis
	  - Allodynia (pain inspite of non-painful stimulus)
	  - Skin is tender
	  - Treatment can reverse manifestations
  Stage II - DYSTROPHIC (3-6 months)
	  - Pain
	  - Stiffness of the hand
	  - Hyperhydrosis
	  - Atrophy of the skin
	  - Cold
	  - Decease hair growth
	  - Patchy osteoporosis
  Stage III - severe atrophy of the subcutaneous tissue and skin
	  - Shiny
	  - Glossy
	  - Scaly
	  - Dry skin
	  - Course hair and rigid nails
	  - Generalized osteoporosis of the bone
	  - Very severe LOM

  -  Tx: physical modalities for pain, desentization by vigorous massage,
       vigorous exercise, stretching, hydrotherapy, pneumatic compression,
       temperature biofeedback
  -  To diagnose: 3 phase bone scan
  -  Drugs:

  3.  Prednisone – oral analgesics, adjuvant analgesics, anti-convulsant,
       antidepressant
  4.  Sympathetic block – best tx
  5.  Stellate – UE
  6.  Paravertebral – LE at L2 level

  * Complex Regional Pain Syndrome type I – secondary to trauma without
     nerve injury
  * CAUSALGIA	  - complex Regional Pain Syndrome type II
  		  - Nerve injury is the sole requirement
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