Shoulder Pathology

• C4 = AC Joint
• C5 = Lateral Cubital Fossa
• C6 = Palmar Thumb
• C7 = Palmar Phalanx Middle Finger
• C8 = Palmar Phalanx 5th Digit
• T1 = Medial Forearm

• C1 = neck flexion
• C3 = neck side flexion
• C4 = shrug 
• C5 = abduction
• C6 = elbow flexion
• C7 = elbow extension
• C8 = thumb extension
• T1 = interossei

• C4 = Levator Scapulae
• C5 = Deltoid
• C6 = Biceps
• C7 = Triceps
• C8 = Extensor Pollicis Longus
• T1 = Thenar Muscles

• Tumor invades upper chest wall (upper 2 ribs) & brachial plexus
• c/o scapular and shoulder pain
• Radicular symptoms to C7, C8, and T1
• Sensory changes (ulnar nerve)
• Passive neck side flexion to contralateral side = limited and painful
• Isometric side flexion to ipsilateral side = painful and weak
• Potential absent triceps reflex

• Lung, breast cancer, and lymphoma
• Pain in paraspinal region radiating to both shoulers
• Tenderness over spinous process
• Nerve root compression - C7, C8, T1

• *Intrinsic hand weakness, triceps, wrist flexors
• *Numbness & paresthesia

• Innervated by phrenic nerves
• C3, C4, C5 (motor and sensory)
• Diaphragm compression can refer pain to shoulder (Supraclavicular nerve C3-C4)

Liver, spleen, gallbladder, compression of diaphragm → sensory fibers (phrenic n.) receive pain signals → signals to spinal cord C3,4 and 5 → brain perceives signals → sends pain sensation to shoulder

• Right Shoulder: Liver & Gallbladder
• Left Shoulder: Spleen

• Mechanism: shoulder dislocation
• Atrophy of deltoid
• Sensory changes in C5 dermatome (inferior region of deltoid (sup. lat. cutaneous n.))
• Motor changes in C5 dermatome (deltoid, teres minor)

• Spurling:
• Pt. moves neck into ext, lat flex, and rotation towards side of pain
• Downward compression applied to head
• (+) = radicular pain or paresthesia in dermatomal distribution (secondary to pressure on inflamed nerve root/spinal cord)

• Bakody's Sign:
• Cervical nerve C4-C5
• Raise affected arm over head to rest on top
• (+) nerve compression if relief of radicular symptoms

• Flattening, erosion posterior glenoid
• Posterior subluxation of humeral head
• Deformed humeral head shape

• Mechanical - RC tear, AP instability, long head biceps tear
• Nutritional - inadequate diffusion, diminished synovial fluid

• Systemic inflammatory disease of connective tissue
• Synovial inflammation of subacromial - sub deltoid bursa

• Symmetric involvement
• Painful abduction w/ shoulder to 90 degrees bilaterally
• Long term corticosteroid use → RC tear

• Degenerative (often seen w/ RC pathology or impingement) 
• Post-traumatic (fall on outstretched arm)

• C/O local pain (directly over AC joint)
• Pain w/ flexed-adducted position, over head motion

Primary: idiopathic (insidious onset; unilateral)

• Secondary: associated w/ known condition
• Post traumatic (immobilization)
• Disease process (diabetes, post-mastectomy, RA, CVA/hemiplegia)

Trigger → inflammation of synovium & jt capsule → capsular fibrosis (collagen deposition) → decreased intra-articular volume/capsular compliance (humeral head tight against glenoid fossa) → global loss of AROM/PROM

• Stage I & II: Painful Stage - "Freezing"
• Progressive loss of motion w/ consistent pain
• Capsular pattern: ER → And → IR (global motion loss)

• Stage III: Adhesive Stage - "Frozen"
• Stiff restricted shoulder w/ minimal pain
• Compensatory motions - decreased inf. glide → shoulder hike

• Stage IV: Recovery Stage - "Thawing"
• Slow, gradual increase in ROM
• Recovery is spontaneous but frequently incomplete

Static components: capsular ligaments, labrum, intra-articular pressure

Dynamic components: rotator cuff, deltoid, long head of biceps

• Hill-Sachs Lesion
• Dislocation: compression fracture on posterior humeral head @ site of impact on inferior glenoid rim
• Subluxation: repetition of contact between humeral head & glenoid (lesion on posterior humeral head)

• Bankart Lesion:
• Avulsion of anterior inferior labrum from glenoid rim

Tears (RC, SLAP)

Impingement

• Subjective reports of "clunk" or "click"
• Subjective reports of "dead arm" or general heaviness (SLAP)
• Diffuse soreness → multidirectional
• Pain location dependent on area of instability

• Sulcus Sign
• Posterior Instability
• Anterior Instability
• Apprehension
• Relocation

Primary: static (outlet impingement)

Secondary: dynamic, repetitive microtrauma (extrinsic)

• Static
• Subacromial outlet impingement (mechanical impingement of RC tendon beneath acromion; secondary to compromise of subacromial outlet space)
• *Subacromial outlet contains humeral head, acromion, coracromial arch & acromioclavicular ligament 

• Causes:
• Acromion shape (curved or hooked)
• Acromioclavicular osteophytes 
• Thickening of coracromial ligament

Neer's Three Stage Classification:

• Stage I: younger patients (<25); acute inflammation
• Stage II: ages 25-40; fibrosis and tendonitis 
• Stage III: >age 40; partial/complete RC tear; osteophytes at coracromial arch

Pain reported w/ forward flexion and IR position (elevation) -- greater tuberosity approximates acromion & coracromial arch

Typically older patients

• Neer Impingement
• Hawkins-Kennedy Impingement Test

Dynamic: relative narrowing of outlet secondary to abnormal humeral head movement w/ activity

• Mechanism:
• → RC imbalance (weakness,tear)
• → Ligamentous instability 

• Clinical Presentation:
• →Typically younger patients
• Symptoms activity specific (overhand activities)

• Type I: Fraying of labrum (degenerative)
• Type II: Detachment of superior labrum & origin LHB
• Type III: Bucket handle tear (labrum torn and displaced into joint)
• Type IV: Bucket handle that extends into biceps tendon 

• *Type III and IV: linked to traumatic instability
• *Type II and IV: result in instability of biceps-labral anchor (more common!)

• Fall onto outstretched arm (FOOSH) - compression injury
• Traction tension on biceps tendon (LHB attaches to labrum in 50% of population)

• Crank Test: (+) = symptomatic click or grinding or clunk
• O'Brien Test: (+) = relief of pain or popping w/ 2nd test position (sensitive and specific!)
• Biceps Load II: (+) = pain w/ resisted elbow flexion

• Biceps pain w/ elbow flexion
• Pain w/ overhead activities 
• "Dead arm" when throwing
• Occasional popping/clicking in the shoulder

• Compression (space attrition; instability → impingement)
• Tensile overload
• Macrotrauma

• Drop Arm Test
• Lift Off Test
• Belly-Press Test
• External Rotation Lag Sign

• LHB = attachment to labrum, SLAP
• → Stabilizes and decelerates in throwing 

Mechanism → Tendonitis (impingement - passes beneath anterior edge of acromion

Subluxing LHB - tear of transverse humeral ligament

Speeds Test

• Primary - associated w/ systemic disease, degenerative changes
• Secondary - associated w/ other shoulder pathology (trauma, overuse) 

• Clinical Presentation:
• → Empty end-feel (abduction = subacromial; ER = subcoracoid)
• → Painful arc
• → Non-capsular pattern

Traumatic: fall on shoulder w/ arm adducted to side

1: Ligaments intact, (-) X-ray

• 2: A-C ligament tear, intact or sprained C-C ligaments
• →Clavicle unstable
• →AC space seen on X-ray

3: A-C and C-C ligament tear, downward displacement of acromion

4: Similar to type II w/ posterior clavicle dislocation

5, 6: Gross displacement of clavicle

Traumatic: FOOSH (anterior dislocation more common than posterior)

• I: Intact ligaments, stable joint
• II: SC subluxation w/partial capsular and ligamentous disruption
• III: SC ligaments and capsule completely disrupted w/ anterior or posterior dislocation

• Stretch/compression of c-spine (Stinger or Burner Syndrome)
• Burning or paresthesia throughout ambiguous dermatome distribution
• Transient loss of ROM and muscle weakness

Compression of neural or vascular structures passing through thoracic outlet

• Mechanisms:
• → Primary = cervical rib, clavicle, scalenes
• → Secondary = postural variation

• Numbness and tingling in hand
• Decreased circulation or "falling asleep" sensation in UE w/ overhead motions
• Pain in interscapular area, medial arm, forearm, hand
• TTP over scalenes
• Paresthesia w/ UE elevation

• Allen
• Adson