Probleme Ale Umarului

8/13/2019 Probleme Ale Umarului

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Student Learning Objectives

Identify the etiology for rotator cuff tearsDescribe the clinical manifestations of rotator

cuff tearsDevelop a management protocol for rotator cufftearsDefine shoulder instability

Differentiate between the dislocators &subluxatorsDescribe the forms of instability



SLOs

Explain the clinical presentation of apatient with instability and how it should be

managed.Describe the MOI for labral tearsCite the types of SLAP lesions, clinical

manifestations & treatmentDescribe the MOI, clinical manifestations, &treatment for AC, SC sprains & capsulitis





History

Typically in 40 + individuals secondary torepetitive activities (degeneration - Neer Stage 3)

or younger pt who experiences trauma (hx ofrepetitive activity that creates degeneration orone traumatic event)Sx’s = Pn, esp. w/overhead activities, night pn, weakness, limited motion esp in elevation;rotation may also be limited depending on weartear is



Examination

Atrophy &/or defects of a tendon in longstanding tears

Tenderness over cuff, biceps; edema;tendon defectsROM is limited w/altered scapulohumeral

rhythm+ Impingement, Codman’s, etc. Mm weakness



Special Studies

Radiographs may benegative or show

degenerativechanges. Possiblesuperior migration ofhumeral head



Special Studies

Arthrography -definitive diagnosis

MRI - may or may notshow tear



Management - Phase 1 (Pain Control)

RestPhysiotherapy

MobilizationCounter force BracingROM exercises

Strengtheningexercises for rotationFull body conditioning



Management - Phase 2 (RestoreROM)

MobilizationROM exercises (stick or towel)Stretching exercisesPulley/Wall climb/Pendulum

Postural trainingFull body conditioning





Management - Phase 3 (Normalizestrength)

IsometricsIsotonic

strengtheningContinue full bodyconditioning

Eccentricstrengthening of cuffIsokinetic exercises





Management - Phase 4(Proprioception)

Proprioceptiveretraining (gymball

pushups & balance apole)Progressiveresistance exercisesPlyometrics(involving vertical &horizontal movements



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Phase 5 – Sport Specific TrainingExercises

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Shoulder Instability



Definition

Humeral head mayundergo a subluxation

or a dislocation. Ineither case thestabilizing forces maybecome laxed leading

to instability



Etiology/pathogenesis Acute First-timeDislocation• Indirect - ext rot, abd,

ext leverage• Direct - traumatic• Speed plays a role-ligs

are weakest w/rapid



Etiology/pathogenesis

Recurrent anterior subluxation• Acute injury or overuse causing stretching of

anterior stabilizersRecurrent anterior dislocation• Trauma disrupts anterior stabilizers

• Laxed (multidirectional laxity) shoulder thatundergoes minimal trauma





Epidemiology

Shoulder dislocation prevalence 1%-2% Anterior instability accounts for 95% of allshoulder instability problemsRecurrence rate may be 92% Younger the pt at first time dislocation the

higher the rate of recurrenceHigher incidence in people involved inthrowing sports



Types of GH Instability

TUBS (Born Loose)• Traumatic

• Unidirectional• Bankart deformity• Surgical

AMBRI (Torn Loose)• Atraumatic

• Multidirectional• Bilateral laxity• Rehab helps• Inferior capsule may

need tightened



Clinical Manifestations

Dislocation - acute pain and deformityfollowing traumaInstability - humerus may give way, have vague discomfort, apprehension,paresthesias, weakness. Usually occurs in

a specific position or action of the arm. Ptmay have sx of Impingement, tendinitis,bursitis.




Possible generalized laxityDead Arm Syndrome - anterior subluxators• Sharp pain w/extreme external rotation or

following a blow to shoulder• Immediate loss of muscle strength

• Pain may subside quickly but strength returnmay take minutes to hours to days.



Diagnosis

HistoryInspection - dislocation, atrophy, winging

Palpation - point tenderness over GH, AC, SC jts ormusclesROM - diminished or excessive in some ranges, weakness

(+) tests for laxity/instability, (+,-) labral tears &Impingement/tendinitisImaging



Anterior Inferior



Hill-Sach’s

Affects posterolateralhumeral head

Typically results fromimpaction of theanteroinferior surfaceof the labrum on theposterolateral aspectof the humeral headduring dislocation.



Bankart’s

Detachment of theanterior band of

inferior glenohumeralligament from thelabrum.



MRI

Acute• Hemarthrosis• Rotator cuff contusion• Hill-Sach w/bone

marrow edema• Torn labrum• Torn, discontinuous

capsule

Chronic• Intra-articular loose

body• Hill-Sachs w/o edema• Subchondral cysts on

head• Fragmented labrum• Thickened capsule• Thinning of articular

cartilage



Management

If the GH joint is dislocated, reduction mustbe performed.

Immobilize after reduction for a few days to weeks depending on whether patient isacute dislocation or recurring subluxator

and their age.







Phase 1

RestPossible use of animmobilizerPt still goes through wrist/hand rom andearly shoulder rom

avoiding ext rot, abd &distractionNSAIDs andphysiotherapy



Phase 2

Ice, NSAIDsRestoring ROM -

passively initiallyScapulothoracicarticulation=protract/retract;elevate/depress



Phase 3

Mobilization to stretch tighten capsule (1-2 weeks post-injury)

Perform ROM & strengthening exercisesprior to 45 degrees of abd. When strengthimproves & pn decreases move up higher



Phase 4

Continue ROM exercisesContinue Strengthening exercisesInitiate proprioceptive retraining



Phase 5

Prepare pt to return to activityStrengthening activity/sport specificEndurance trainingSpeed training - plyometrics



Phase 6

Return to sportContinue to work on any strength orfunctional deficits.



If shoulder remains unstable:

Activity modification for those who haveinstability with certain activities (sport)

and willing to give up the sportSurgery for those who are unwilling tomodify activities or who have instability

during their ADLs



Surgery

Evaluate the full extent and direction of instabilityunder anesthesia (mm are relaxed)

Arthroscopy – capsule, ligaments tightenedOpen Surgery – structures are repaired,reattached &/or tightenedRehab = ROM of elbow, wrist, hand day after; most

can write & eat w/in a week; Supervised PTinitiated 1-4 wks post-surgical; Full ROM return 6-8 wks, Strength w/in 3 months; return to play maybe 1 yr



Glenoid Labrum Tears

MOI• Excessive traction - inferior or superior

traction• Compression – fall on outstretched arm w/

shoulder in flexion and ext rotation

• Chronic overuse/age related = instabilitySLAP lesion is most common type of labraltear

f



SLAP Lesions-extend from ant topost to biceps tendon




Seen in conjunction w/other shoulderpathologies

Poorly localized pnExacerbated by overhead or behind theback motions

Popping, clicking, grinding, tendernessROM changes esp over 90(+) Clunk & other labral tests



Special studies

XRay may be:• Normal• Show loose bodies,

degenerative changes,Bankart or Hill-Sach,diminishedsubacromial arch

MRI• Shows defect

Arthroscopy



Management

Similar concepts as with instability rehab.Rest

NSAIDs & physiotherapy forpain/inflammationROM

Strengthening exercisesPossible surgical repair if the patientshows no signs of improvement within 2-4 weeks of treatment.



AC Sprains - MOI

Trauma - elevation, depression, retractionor A-P translation will injure AC & SC joints

Direct - direct downward blow to clavicle orfall on point of shoulder w/arm at side oradducted

Indirect - fall on outstretched arm or lateralborder of the shoulder



AC Sprains

Two classifications• Grades I - III

• Type I - VI



Grade I

MildMinimal pain &

swellingTenderness at AC ligNo instability

Tight Traps



Grade II

ModerateMarked pain, edema,

instabilityTorn capsule & AC ligPainful arc abd, ROMloss, tight trapsPossible gapping w/stress films



Grade III

Severe – completeseparation

AC & CC ligaments aretornPain, tenderness, stepdefectR/O concurrentfracture



Types I - VI

I: sprain without a complete tear, clavicle isnot displaced.

II: Complete tear AC lig & partial tear of CC lig.The clavicle is slightly displaced.

III: Complete tear of AC & CC ligs. clavicle is

dislocated.IV V VI: Complete tear of AC & CC ligs. Theclavicle is severely dislocated & usuallyrequires surgical intervention.



Diagnosis

HistoryPalpation

ROMProvocative testsImaging





Management

Therapy depends onthe grade.

Rest w/possibleimmobilizationNSAIDs &physiotherpayROM & strengtheningIII maybeconservative or

surgery





SC Sprains

Not commonThree types

• I – mild pn & edema; Tx w/ice & NSAIDs

• II – moderate pn & edema;ROM is effected; Tx may

need a sling or figure 8harness; possible residualbump at jt

• ROM exercises for I & II

initiated w/10 days



SC Sprains

III – complete jt dislocation (anterior orposterior; anterior more common) Anterior reduced; pt supine, w/rolled towelbetw scapula, arm is tractioned and abducted while direct pressure is applied to claviclePosterior dislocation will probably require anopen reduction although try closed reduction

firstImmobilized in a splint for 4-6 wks w/gradualrestoration of motion



Adhesive Capsulitis



Definition & Epidemiology

Condition of unknown etiologydistinguished by painful restriction of

almost all movements on both active &passive ROM (esp abduction & ext. rot) Affects 2%-5% or population

F>MBetw 4 th & 6th decades



Etiology

Unknown but causes inflammation &adhesions

Primary (idiopathic)Secondary• Intrinsic - problem in shoulder

• Extrinsic - problem outside shoulder• Systemic disease



Pathogenesis

Synovitis in earlystages.

Intra-articularadhesions in axillaryfoldCapsular thickeningat coracohumeral &sup gh ligsFibrosis



Stages

Painful (Freezing) = severe pn, night pn &gradual loss of joint volume & motion; lasts

10-36 wks Adhesive (Frozen) = pn decreases, ROM lossdoesn’t change; lasts 4 -12 months

Recovery (Thawing) = gradual return ofmotion; lasts 12 months or years



History

Initially a generalized ache that mayradiate

Becomes a moderate to severe pain &stiffnessPatient reluctant to move arm so difficulty

in performing normal ADLsNight pain so sleep loss



Px

Possible atrophy ofshoulder girdle mmROM loss usually followsa capsular pattern oflimitation (abd, ext rotfirst & most, int rot, flex,add, extension)Increased scapularmotionJt hypomobility = GH, AC,SC & lower cervicals



Management

Conservative• ROM exercises

• NSAIDs and analgesics• Manipulation/mobilization of shoulder

girdle and other joints as indicated

• Possible MUA• Education - no pain no gain (to a point)• Home exercises

• Physiotherapy for pain control



Management - Allopathic

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Probleme Ale Umarului