VARIOUS SHOULDER PATHOLOGIES IN YOUNG ACTIVE INDIVIDUALS

1. COMMONSHOULDER PATHOLOGIES
IN YOUNG ADULTS
DR S.K.NAYAK
SENIOR RESIDENT
PHYSICAL MEDICINE AND
REHABILITATION

2. THREE CATEGORIES OF
PATHOLOGIES
• INSTABILITY
• IMPINGEMENT
• ROTATOR CUFF INJURY

3. INSTABILITY-
• OCCURS WHEN LIGAMENTS, MUSCLES, AND TENDONS NO
LONGER SECURE THE SHOULDER JOINT.
IMPINGEMENT-
• OCCURS DUE TO THE FREQUENT ACTIVITIES LIKE EXCESSIVE,
REPETITIVE AND HECTIC SHOULDER MOTIONS.
ROTATOR CUFF INJURY-
• OCCURS IN ATHLETES PARTICIPATING IN REPETITIVE
OVERHEAD SPORTS, INCLUDING SWIMMING AND TENNIS.

4. INSTABILITY

5. • THE CLASSIFICATION OF GLENOHUMERAL JOINT
INSTABILITY DEPENDS UPON
– THE DEGREE,
– FREQUENCY,
– ETIOLOGY, AND
– DIRECTION OF INSTABILITY.
• THE DEGREE OF INSTABILITY INCLUDES
DISLOCATION,
SUBLUXATION,
MICROINSTABILITY.

6. • A DISLOCATION IMPLIES THE HUMERAL HEAD IS
DISSOCIATED FROM THE GLENOID FOSSA.
• A SUBLUXATION IMPLIES THE HUMERAL HEAD
TRANSLATES TO THE EDGE OF THE GLENOID.
• MICROINSTABILITY IS ATTRIBUTABLE TO
EXCESSIVE CAPSULAR LAXITY, AND IS
MULTIDIRECTIONAL.

7. THE FREQUENCY OF INSTABILITY CAN BE
ACUTE,
CHRONIC.
• ACUTE INSTABILITY INVOLVES A NEW INJURY
RESULTING IN SUBLUXATION OR DISLOCATION
OF THE GLENOHUMERAL JOINT.
• CHRONIC INSTABILITY REFERS TO REPETITIVE
INSTABILITY EPISODES.

8. • ETIOLOGY OF INSTABILITY INCLUDES
TRAUMATIC
AND
ATRAUMATIC.
• TRAUMATIC INSTABILITY- DISRUPTION OF THE GH JOINT.
• ATRAUMATIC INSTABILITY - CONGENITAL CAPSULAR LAXITY OR REPETITIVE
MICROTRAUMA.
VOLUNTARY
AND
INVOLUNTARY
• VOLUNTARY INSTABILITY REFERS TO AN INDIVIDUAL WHO VOLITIONALLY SUBLUXES
OR DISLOCATES ITS GH JOINT,
• INVOLUNTARY INSTABILITY DO NOT PERFORM THIS.
• MOSTLY ASSOCIATED WITH PSYCHOLOGICAL PATHOLOGY.

9. • INSTABILITY CAN BE
UNIDIRECTIONAL
OR
MULTIDIRECTIONAL.
• UNIDIRECTIONAL REFERS TO INSTABILITY ONLY IN ONE
DIRECTION. THE MOST COMMON IS TRAUMATIC ANTERIOR
INSTABILITY.
• MULTIDIRECTIONAL IS INSTABILITY IN TWO OR MORE
DIRECTIONS .
• USUALLY CAUSED BY CONGENITAL CAPSULAR LAXITY OR
CHRONIC REPETITIVE MICRO TRAUMA.

10. • TRAUMATIC ANTERIOR GLENOHUMERAL
DISLOCATION FREQUENTLY TEARS THE ANTERIOR
INFERIOR GLENOHUMERAL JOINT CAPSULE AND
AVULSES THE ANTERIOR INFERIOR GLENOID
LABRUM WITH OR WITHOUT SOME UNDERLYING
BONE FROM THE GLENOID RIM - BANKART LESION.
• WITH A COMPRESSION FRACTURE OF THE
POSTEROLATERAL ASPECT OF THE HUMERAL HEAD-
HILL-SACHS DEFECT.

13. • INFERIOR GLENOHUMERAL JOINT INSTABILITY
TYPICALLY DOES NOT OCCUR IN ISOLATION.
INCLUDES
CAPSULO-LIGAMENTOUS LAXITY OR INJURY
AND
ABSENCE OF THE GLENOID FOSSA UPWARD TILT.

14. • POSTERIOR GLENOHUMERAL JOINT INSTABILITY.
CONGENITAL GLENOID HYPOPLASIA
OR
EXCESSIVE GLENOID OR HUMERAL RETROVERSION.
• HOWEVER, INCLUDES EXCESSIVE CAPSULO
LIGAMENTOUS LAXITY OR INJURY, OR INJURY TO
THE SUBSCAPULARIS TENDON.

15. • A TEAR OF THE POSTERIOR INFERIOR GLENOID LABRUM
CAUSING SEPARATION FROM THE GLENOID FOSSA RIM,
OFTEN REFERRED TO AS A “REVERSE BANKART LESION,” OR
A FRACTURE OF THE POSTERIOR INFERIOR GLENOID
FOSSA RIM CAN ALSO CAUSE POSTERIOR GLENOHUMERAL
JOINT INSTABILITY.
• A “REVERSE HILL-SACHS DEFECT” CAN ALSO BE PRESENT,
WITH AN IMPACTION FRACTURE OF THE ANTERIOR HUMERAL
HEAD.

17. ADHESIVE CAPSULITIS

18. • ADHESIVE CAPSULITIS (COINED BY NEVIASER) , OR
“FROZEN SHOULDER,” IS CHARACTERIZED BY
PAINFUL, RESTRICTED SHOULDER ROM IN
PATIENTS WITH NORMAL RADIOGRAPHS.
• 4 TIMES MORE COMMON IN WOMEN THAN MEN,
AND IS MOST FREQUENTLY SEEN IN INDIVIDUALS
BETWEEN 40 AND 60 YEARS OF AGE.

19. ADHESIVE CAPSULITIS IS USUALLY AN IDIOPATHIC
CONDITION, BUT CAN BE ASSOCIATED WITH
– DIABETES MELLITUS,
– INFLAMMATORY ARTHRITIS,
– TRAUMA,
– PROLONGED IMMOBILIZATION,
– THYROID DISEASE,
– CEREBROVASCULAR ACCIDENT,
– MYOCARDIAL INFARCTION, OR
– AUTOIMMUNE DISEASE.

20. • ADHESIVE CAPSULITIS HAS BEEN DIVIDED INTO FOUR STAGES
• STAGE 1 OCCURS FOR THE FIRST 1 TO 3 MONTHS AND INVOLVES PAIN WITH
SHOULDER MOVEMENTS BUT NO SIGNIFICANT GLENOHUMERAL JOINT ROM
RESTRICTION WHEN EXAMINED UNDER ANESTHESIA.
• STAGE 2, THE “FREEZING STAGE,” FOR 3 TO 9 MONTHS AND ARE
CHARACTERIZED BY PAIN WITH SHOULDER MOTION AND PROGRESSIVE
GLENOHUMERAL JOINT ROM RESTRICTION IN FORWARD FLEXION, ABDUCTION,
AND INTERNAL AND EXTERNAL ROTATION.
• STAGE 3, “FROZEN STAGE,” PERSISTS FOR 9 TO 15 MONTHS AND INCLUDE A
SIGNIFICANT REDUCTION IN PAIN WITH MAINTENANCE OF THE RESTRICTED
GLENOHUMERAL JOINT ROM.
• STAGE 4, “THAWING STAGE,” SYMPTOMS HAVE BEEN PRESENT FOR
APPROXIMATELY 15 TO 24 MONTHS AND ROM GRADUALLY IMPROVES.

21. IMPINGEMENT

22. • BIGLIANI ET AL FOUND A RELATION BETWEEN THE
ACROMIAL SHAPE AND THE PRESENCE OF ROTATOR
CUFF TEARS ON CADAVERIC EXAMINATION.
• HE CLASSIFIED THE ACROMIONS INTO THREE TYPES
• TYPE 1 ACROMIONS WERE RELATIVELY FLAT, WHEREAS
• TYPE 2 ACROMIONS DEMONSTRATED A CURVE, AND
• TYPE 3 ACROMIONS WERE HOOKED.

24. • SUBACROMIAL, OR “OUTLET,” IMPINGEMENT CAN BE
PRIMARY OR SECONDARY.
• CAUSATIVE FACTORS FOR PRIMARY IMPINGEMENT
INCLUDE A HOOKED ACROMION OR A THICK
CORACOACROMIAL LIGAMENT.
• SECONDARY IMPINGEMENT HAS MANY CAUSES,
INCLUDING
– GLENOHUMERAL JOINT INSTABILITY,
– WEAK SCAPULAR STABILIZERS,
– SCAPULOTHORACIC DYSKINESIS, AND INSTABILITY.

25. • ANOTHER FORM OF IMPINGEMENT, INTERNAL IMPINGEMENT,
CAN OCCUR IN OVERHEAD ATHLETES, WHEN THE ARM IS
ABDUCTED 90 DEGREES AND MAXIMALLY EXTERNALLY
ROTATED.
• THERE IS CONTACT BETWEEN THE UNDERSURFACE OF THE
ROTATOR CUFF AND THE POSTEROSUPERIOR GLENOID RIM.
• THE ANTERIOR APPREHENSION TEST CAN BE USED TO DETECT
BOTH ANTERIOR INSTABILITY OF THE GLENOHUMERAL JOINT
AND ALSO INTERNAL IMPINGEMENT.
• INTERNAL IMPINGEMENT CAUSES PATHOLOGIC CHANGES TO THE
UNDERSURFACE OF THE ROTATOR CUFF.

26. ROTATOR CUFF TEARS

27. • DEPALMA ET AL. DESCRIBED THE FREQUENCY OF
ROTATOR CUFF TEARS INCREASES STEADILY AFTER THE
FIFTH DECADE OF LIFE.
• USING ULTRASOUND EVALUATION, TEMPELHOF ET AL.
STUDIED 411 ASYMPTOMATIC PATIENTS AND FOUND
TEAR RATES OF 23.4% OVERALL AND 38% IN PATIENTS
OLDER THAN 70.

28. • LOSS OF CONTINUITY OF THE ROTATOR CUFF CAN
BE DESCRIBED IN SEVERAL WAYS, INCLUDING
– ACUTE AND CHRONIC,
– PARTIAL OR FULL THICKNESS, AND
– TRAUMATIC OR DEGENERATIVE.

29. FULL-THICKNESS ROTATOR CUFF TEARS ALSO ARE
CLASSIFIED BASED ON THEIR SIZE POPULARIZED BY
COFIELD ET AL., IS BASED ON THE LARGEST
DIMENSION OF THE TEAR:
– SMALL TEARS MEASURE < 1 CM;
– MEDIUM TEARS, 1CM TO 3 CM;
– LARGE TEARS, 3CM TO 5 CM; AND
– MASSIVE TEARS, < 5 CM.

30. • WITH RESPECT TO PARTIAL-THICKNESS TEARS, ELLMAN
PRESENTED A CLASSIFICATION WITH DESCRIPTIONS OF
LOCATION –
– ARTICULAR,
– BURSAL, AND
– INTERSTITIAL.
• GRADES- DEPTH OF TEARS
– GRADE 1, TEARS- <3 MM DEEP;
– GRADE 2, TEARS- 3 TO 6 MM DEEP;
– GRADE 3, TEARS- >6 MM DEEP.

32. ACROMIOCLAVICULAR JOINT SPRAINS

33. • AC JOINT SPRAINS ACCOUNT FOR ONLY 9% OF ALL
SHOULDER INJURIES, ARE MOST FREQUENT IN MALES, IN
THEIR THIRD DECADE OF LIFE, AND ARE USUALLY PARTIAL
RATHER THAN COMPLETE SPRAINS.
• MOST INJURIES OCCUR AS A RESULT OF DIRECT
TRAUMA FROM A FALL OR BLOW TO THE ACROMION.

34. • ROCKWOOD CLASSIFIED AC JOINT SPRAINS INTO SIX
TYPES -
• TYPE 1-SPRAINS INVOLVE A MILD INJURY TO THE AC
LIGAMENTS, AND RADIOLOGIC EVALUATION IS NORMAL.
• TYPE 2-INJURIES INVOLVE THE COMPLETE DISRUPTION
OF THE AC LIGAMENTS BUT WITH INTACT CORACO-
-CLAVICULAR LIGAMENTS. RADIOGRAPHS MIGHT
DEMONSTRATE CLAVICULAR ELEVATION RELATIVE TO THE
ACROMION BUT LESS THAN 25% OF DISPLACEMENT.

35. • TYPE 3- SPRAINS RESULT IN THE COMPLETE
DISRUPTION OF THE AC AND CC LIGAMENTS, BUT
THE DELTOTRAPEZIAL FASCIA REMAINS INTACT.
• RADIOGRAPHS REVEAL A 25% TO 100% INCREASE IN
THE CORACOCLAVICULAR INTERSPACE RELATIVE TO
THE NORMAL SHOULDER.
• TYPE 4- TYPE 3 WITH POSTERIOR DISPLACEMENT OF
THE DISTAL CLAVICLE INTO THE TRAPEZIUS MUSCLE.

36. • TYPE 5 SPRAINS- TYPE 3 WITH A RUPTURE OF THE
DELTOTRAPEZIAL FASCIA.
• TYPE 6 SPRAINS- TYPE 5, WITH DISPLACEMENT OF
THE DISTAL CLAVICLE BELOW THE ACROMION OR
THE CORACOID PROCESS

37. ROCKWOOD CLASSIFICATION OF AC JOINT SPRAIN

38. THANK YOU