Shoulder, Clavicle, Scapula And Elbow Dysfunctions

*Rotator Cuff Tendonitis: Long term, loss of motion, weakness, overuse, wear and tear,

*Rotator Cuff Tears:

-Partial or full thickness, acute, chronic, traumatic, degenerative (aging)

-Presentation: pain, weakness, decreased function, crepitus (pops)

*More often see Partial Tears

*Common in age 50 or up

*subacromial space/coracoacromial arch

*Bursa, supraspinatus tendon, biceps tendon, joint capsule, nerves, arteries and veins

*Activities above 90 degrees elevation (Flexion, Extension, Abd/Adduction)

*Primary impingement- space is narrowed

*Secondary impingement- mechanical/functional

ex/ The way the scapula and tendon move together

Clinical Presentation - Decrease mobility of posterior capsules, Blood supply restricted due to being pinched (supraspinatus)

Type 1 - Flat

Type 2 - Round

Type 3 - Hook

Other types of impingement- Wearing of tendons, bursa inflammation and specific pain

Posterior impingement

*Other muscles are trying to help, but will not always work

*Subacromial bursa

*Long head of biceps

- Takes over for dysfunction muscles during impingement

*Treatment: Therapy first, 90 degree limitations, then surgery (subacromial decomposition) which is the shaving of the clavicle

*Advanced degeneration of humeral head, underside of acromion, and clavicle

*Pain, loss of motion, rubbing of joints surfaces, altered mechanisms

*Traditional Total Shoulder/ Reverse Total Shoulder

*Replace gleniod & head of humorous

*Total Shoulder gets you back about 60% of function

*AKA Frozen Shoulder

*Traumatic or insidious onset

*Often occurs along RTC involvement (decreased mobility)

*Thickening of synovium of shoulder joint capsule

*Adhesion of joint capsule and surfaces leading to loss of motion, pain, and stiffness

*Incidence -

*More often in Women

*50-70 years old

*diabetics - insulin increases damage to capsule

Clinical Presentation - Loss of both PROM and AROM, Firm end feel, capsular pattern (loses in all directions, some more than others)

Stages- 1. Freezing Stage 2. Freeze 3. Thaw

*Therapy involved, a lot of PROM and stretching.

*Patient put to sleep and then manipulated, a lot of popping occurs, but ROM is a lot better.

*Subluxation- voluntary/involuntary that will go out on their own

*Dislocation- joint surfaces come uncontacted, can not go in by itself

*Instability - Increased laxity/weakness in joint, sloppy joint (no limits)

*Laxity - passively move humeral head off glenoid

*Incidence

-Anterior and inferior (most common)

-Men > Women

- Multiple dislocations (must have 3 for surgery)

*Clinical Presentation

-Hypermobility

-Feelings of sliding of joint surfaces with passive mobility

-Typically painless

*Ligaments 0 Bankart Lesion

*Capsule

*Greater Tubercle

-Hill Sach's Lesion

*Labrum

*RTC

*Vascular Damage

*Brachial Plexus Damage

*Reduce ASAP (and put back in place)

*Bankart Repair - AGHL and labrum repaired

*Capsular pattern - tighten capsule to make stronger

*Thermal Capsular Shrinkage - Heat and cool capsule to make it shrink

*Traumatic or atraumatic

*Labrum is like the meniscus in the knee

- Dinner plate?

*SLAP Lesion - superior labrum anterior - posterior

*Types 1-4

-Type 2 (Long head of biceps tears off and 3 (Bucket handle) are most common

*Trauma

*Midsection of clavicle

Falls

*Football injuries

*Common in teens and older adults

Scapular Winging - Comes from pulling

*Vascular and neutral compression anteriorly causing referral into UP

*Structural contributors- cervical ribs (space issue) tight chest muscles, large breasted women

*Mechanical contributors - heavy backpack, repetitive overhead use

Clinical Presentation?

*Ulnohumeral Joint

*Radiohumeral Joint

*Promixal radioulnar joint

*Middle radioulnar articulation

*UCL - ulnar collateral ligament

*Olecranon

*Radial Head

*Supercondylar humeral fx

*General rule for elbow fx:

-Non displaced are not surgically repaired

- Displaced are surgically repaired

*Body of olecranon fractures off the ulna

*Fall onto outstretched arm, direct blow

*Post fracture instability changes joint mechanics

*ORIF - instability in elbow later on

*Coronoid process of the olecranon

*Provides stability

*High impact injuries or with dislocation

*Radial head fractures off shaft of radius

*MOI- fall onto outstretch shoulder or dislocation

*Necessary for stability against value stress

*Surgical intervention

- mindful of promixal radial migration

*2nd most commonly dislocated joint

*High incidence in children

*Fall onto outstretched arm

*Fractures commonalty occur with dislocations

*Medical intervention-

-reduce ASAP

-rule out fx

*Dominant arm, middle aged men

*Sudden, forceful overload in midrange flexion

*Presentation

-Popeye deformity

-Forearm weakness

-unable to supinate/pronate

*Surgical repair-

-Has to be repaired, bones can fuse distally

*Cubital tunnel syndrome - ulnar nerve (causes tingling and numbness)

*Common in throwers

-2nd most common compression neuropathy to carpal tunnel syndrome, 1st is carpal tunnel

-Ulnar nerve trapped under ulnar ligament and flexor carpi ulnaris tendon

-causes: trauma, traction of area, compression, sublux of elbow, degenerative changes in age

*Presentation- pain along ulnar nerve distribution

Conservative Treatment:

Activity Modification

Rest

Immobilization/elbow stabilized

anti-inflammatory meds

then surgery: translocation of ulnar nerve

*Pronator Syndrome - median nerve

-Median nerve is entrapped in pronator teres and flexor digitorum profundus

-causes: repeated forceful pronation and finger flexion, trauma, compression, gripping and turning

-Presentation: pain along median nerve, anterior elbow and forearm, vascular signs (coldness/numbness) no symptoms at night, pain will radiate distally toward the wrist over area near cmc

Conservative treatment: Same as Cubital tunnel

Surgery: Nerve decompression (create space for nerve to function)

*Tennis Elbow

*Most common overuse injury in the elbow

*Extensor wad - extensor carpi radialis brevis

*Treatment: steroids, PT streching, surgically removing abnormal tissue

*Surgery: Releasing structures and introduce healing

Posterior interosseous branch of radial nerve trapped in extensor carpi radiallis brevis and supinator muscle

*Golfers elbow

*May also involve ulnar nerve

*Causes: Repititive vagistress, tennis (forearm stroke), golf, over head-throwing

*Presentation: Tender, pain with resistive testing and passive stretching of involved structures

*Treatment: more steroidal injections, not as successful as lateral epicondylitis

*Repitive valgus stress

*Overhand throwers (youth especially), tennis, golfers

*Presentation: tender over medial epicondyl, pain over medial elbow, pain during throwing, can lead to a rupture of UCL

Surgery: Replace the ligament with palmarus longus or extender hallicus ligament

*Bone formation in nonosseous tissues

-Bone where it does not need to be

-Surgically: ulnar nerve transposition and removal of bone growth

Presentation: pain, swelling, stiffness, loss of ROM

*Typically occur in promixal humerus

*Very young or elderly (due to osteoporosis or fracture from fall with an outstretched arm)

*Little Leaguer's Shoulder: caused by forceful release

*Promixal Humeral Fx