a. Rotator cuff
i Tendinopathy & Tears
Rotator Cuff Pathology
The shoulder joint is a fascinating, intricate joint that relies on the coordination of a huge number of muscles around the scapula (shoulder blade) and humerus (arm bone) to function normally. Unlike most joints of the body, the shoulder relies on active (muscular) structures for stability as opposed to bony congruency.
The 4 muscles primarily responsible for maintenance of shoulder stability are termed the rotator cuff:
- Teres Minor
Acute trauma or long-term overuse of the shoulder may lead to a variety of rotator cuff pathology including tears (partial or full thickness) and tendinopathy. Common signs and symptoms of rotator cuff pathology include:
- Pain with overhead activity (elevation above 90 degrees) such as pressing, throwing or serving in tennis
- Night pain
- Pain and weakness with resisted external rotation, full/empty can testing
c. Glenoid labrum injuries
The glenoid labrum is a fibrous tissue attached to the rim of the glenoid, acting to increase the stability of the glenoid. The labrum also aids proprioception, muscular control and spreads load across the joint surface. The shoulder capsule, glenohumeral ligaments and long head of bicep all attach to the glenoid labrum. Labrum injuries are divided into SLAP (superior labrum anterior to posterior) and non-SLAP injuries, in addition to stable or unstable classification.
Presents like this to us: A history of catching a heavy object, or during throwing related activities. Pain with movement, on palpation of the shoulder, and on resisted bicep movements. Over head or behind the back movements are aggravating, with catching, popping or grinding present.
It feels like this at rest and with sport to you: Dependent on severity of the injury you may experience little to no pain at rest to moderate to severe pain with movement or loaded activities.
We look for this in the physical assessment: We look for positive shoulder special tests to distinguish a SLAP lesion from other shoulder pathologies. Active movements behind the back, overhead, and resisted biceps are painful and aggravating.
Dislocation of the glenohumeral joint is a common traumatic injury resulting from the arm being forced into excessive abduction and external rotation. There may also be internal trauma affecting the glenoid labrum (Bankart lesion) or fracture (Hill-Sachs lesion).
Presents like this to us: Acute trauma, with a sudden onset of pain. Injury maybe direct or indirect in nature. Popping out sensation and associated audible noise at time of injury.
It feels like this at rest and with sport to you: Acute pain, limited range of motion and strength compared to the unaffected side.
We look for this in the physical assessment: Loss of strength and range of motion. Occasionally loss of sensation from axillary nerve damage. Prominent head of humerus and gap below the acromion.
f. Adhesive capsulitis
Adhesive capsulitis (frozen shoulder) is characterised by loss of shoulder range of motion, coupled with pain on movement and at night. The cause of adhesive capsulitis is unknown; however, the condition commonly affects individuals aged 40-60 years, women more than men, diabetics, thyroid conditions, and may present in post-operative shoulders.
Presents like this to us: Depending on the stage of the condition (freezing, frozen or thawing). Freezing stage – pain with movement, at rest, at night (may last 3-12 months). Frozen stage – progressive stiffness, pain at end of range (3 to 12 months). Thawing – resolution of movement and symptoms (2 to 8 months).
It feels like this at rest and with sport to you: Depending on the stage of the condition (freezing, frozen or thawing). Freezing stage – pain with movement, at rest, at night (may last 3-12 months). Frozen stage – progressive stiffness, pain at end of range (3 to 12 months). Thawing – resolution of movement and symptoms (2 to 8 months).
We look for this in the physical assessment: Decreased shoulder range of motion, with active range equal to passive range. Depending on stage – pain on movement/ end of range.
g. AC Joint
Acute acromioclavicular (AC) joint injuries occur due to trauma, often a result from either a direct force onto the edge of the shoulder or from an indirect force to the AC joint (e.g. fall onto elbow driving the upper arm up and disrupting the AC joint. The AC joint is stabilised by the acromioclavicular joint and coracoclavicular ligaments.
There are six grades of AC joint injuries used to classify severity:
- Sprain of AC ligaments
- No instability
- Rupture of AC ligaments and CC ligaments are intact.
- Clavicle is unstable to stress
- Complete rupture of both AC and CC ligaments
- Deformity present, clavicle presents elevated
- Distal clavicle is displaced into trapezius muscle
- Posterior deformity
- Rupture of AC and CC ligaments with disruption of deltoid and trapezius fascia
- Clavicle elevated, scapular displaced downward
- Inferior displacement of the distal clavicle
- Severe trauma, commonly accompanied by other injuries
A patient will typically present with a history of mechanism of injury, pain on palpation of the area and deformity depending on the grade of injury.
You can expect to have limited shoulder range of motion with increasing severity of injury. A grade 1 injury commonly presents with pain with shoulder abduction, while grade 2 are commonly painful with all shoulder movements. Grade 3 + demonstrate a notable step deformity, with the patient supporting the arm close to their body.
h. SC Joint
Sternoclavicular joint pathologies are often the result of trauma to the shoulder resulting in disruption of the ligaments that support and maintain the joint. Subluxation or dislocation of the joint may occur.
i. Clavicle fracture
Clavicle fracture commonly occur in the middle-third of the bone from direct or non-direct contact to the shoulder. An acute clavicle fracture is usually very painful.
Presents like this to us: tenderness and swelling, bone deformity may be present. Pain inhibition limiting shoulder and arm range of motion and strength on the affected side.
It feels like this at rest and with sport to you: acute pain, limiting movement to the affected side
We look for this in the physical assessment: Marked tenderness and swelling, possibly bony deformity. Bruising around the clavicle and shoulder often suggests assoicated muscle strain or tear.
i. Tendinopathy & Tenosynovitis
The bicep, in particular the long head of biceps, is susceptible to overuse injuries. The long head of bicep attaches to the top of the glenoid, passing through the bicipital groove. Often injury occurs in periods of high training volume, coupled with dysfunctional training form in movements such as bench press or dips.
Tendinopathy is a general term used to describe tendon dysfunction, while tenosynovitis is the term used for inflammation around the sheath of the tendon.
Presents like this to us: tenderness on palpation of the long head of biceps tendon, pain with shoulder movements overhead or resisted elbow/ shoulder flexion.
It feels like this at rest and with sport to you: symptoms will vary depending on the degree of tendinopathy. Commonly morning pain is reported, before symptoms reduce once warm to a degree, with aggravation following cooling down period. In severe cases, the bicep may be easily aggravated.
We look for this in the physical assessment: tenderness on palpation of the long head of biceps tendon, pain with resisted shoulder/ elbow flexion, pain on passive stretch.
We initially manage these by implementing this: manual therapy, NSAID’s, ice, activity modification and isometric exercises
Longer term we look to do this to aid prevention and performance: Restoration of shoulder range, strength, neuromuscular control, endurance and power.
For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.
iii. Rupture & Pec Major tears
Rupture of tendons around the shoulder commonly include the long head of biceps or pectoralis major. Rupture of the long head of biceps is more prominent in older individuals where the bicep has been placed under load. This is often accompanied by a tearing sensation and acute sharp pain. A clear deformity presents from a rupture, with the attachment bunching in the arm. We look for pain on resisted elbow and shoulder flexion. Orthopaedic review of surgery is indicated for individuals requiring power during sport.
Rupture of the pectoralis major usually occurs at the insertion in the humerus, and is commonly seen in weight lifting where the bench press is performed. We look for pain on resisted tests, weakness, swelling, bruising and tenderness in the area. Rupture of the tendon requires surgery, while partial tears may be conservatively managed for 4-6 weeks with strengthening and ice.
k. Nerve entrapments
Nerve entrapments to the suprascapular nerve, long thoracic nerve or axillary nerve may result in shoulder pain. The suprascapular nerve innervates the supraspinatus and infraspinatus rotator cuff muscles, and is the most common nerve entrapment of the shoulder. Symptoms are often described as a deep pain that is poorly localised at the back/ side of the shoulder. Symptoms may refer into the arm or neck, with associated shoulder weakness. We look for wasting of the supraspinatus or infraspinatus muscles, with weakness on resisted tests into external rotation and abduction. Often surgical decompression of the nerve entrapment is required.
l. Thoracic outlet syndrome
Thoracic outlet syndrome is the compression of neurovascular structures through the thoracic outlet from the neck. Commonly compression occurs between the clavicle and first rib, however may occur between the anterior and middle scalene, or the coracoid process and the pectoralis minor. A history of overhead sport and activity is common. Dysfunctional postural patterns of shoulder and scapular control can reduce the space for neurovascular structure from neck to shoulder and result in symptoms. Patients will often report of pain in the neck or shoulder, with associated pin and needles or numbness referring into the forearm. Weakness, fatigue or coolness in the arm of the affected side may be experienced.
Fractures of the shoulder joint are less common than other shoulder conditions. Fractures are classified on level of severity and complexity of disruption to the bone. Commonly non-displaced fractures are conservatively managed in a sling or brace, with gradual introduction of range of motion and strengthening exercises as tolerated. Displaced fractures will often require orthopaedic review and surgery, with rehabilitation following surgery. We look for localised pain, weakness on resisted tests, and limited range of motion of the shoulder joint.