Musculotendinous and Labral Pathologies of the Shoulder

 

Rotator Cuff Impingement

Rotator Cuff Tendinitis

Bicepital Tendinitis

Superior Labrum Anteroposterior Lesions

Thoracic Outlet Syndrome

  Rotator Cuff Impingement

 

Pathology
  • The muscles of the rotator cuff must pass inferior to the rigid coracoacromial arch and superior to the head of the humerus during shoulder mobilization 

  • Impingement occurs when there is not enough space for the rotator cuff in this subacromial space.

Etiology: Causes of Impingement

 


Destructive Impingement Cycles

 

Inflammation – Inflammation due to irritation caused by impingement results in swollen muscles.  These take up more space and increase the level of impingement 


 

Loss of Function – The rotator cuff muscles are crucial in pulling the head of the humerus inferiorly sustaining the subacromial space during abduction.  If these muscles are damaged due to impingement they may not be able to perform this function, increasing the level of impingement (Starkey & Ryan 2002).

Adopted from Starkey & Ryan 2002

 

Acromion types I,II, &III:

 

  • Type I: flat, minimal impingement risk, normal subacromial space
     
    Type II: curved, higher rate of impingement, slight decrease in subacromial space
     
    Type III: beaked, highest rate of impingement, marked decrease in subacromial space

 

Force Source
Primary compression

-Irregularly shaped acromion


-Coracoacromial ligament

-Enlarged Bursa

-Thickened rotator cuff tendons
Secondary Compression

-Loss of humeral head depression

-Poor posture

-Repetitive full abduction
Primary Tensile

-Repetitive overload

-Eccentric forces
Secondary Tensile

-Scapular impairment

-Glenohumeral instability

-Rotator cuff weakness

 

 

 

Signs and Syptoms

 

 

 

  • Severe pain is felt when the arm is lifted into overhead position.
  • There is tenderness over the outside of the shoulder joint.
  • Weakness may occur in the arm, at least partly related to pain.
  • Pain may radiate into the arm and into the neck.
    (Source: www.myelectronicmd.com)
 

Special Tests

Treatment
  • Controlling inflammation by a combination of strengthening manuevers and anti-inflammatory agents (ibuprofen or aspirin).
  • With reduced inflammation, further stretching and strengthening can begin the healing process.
  • Strengthening of the rotator cuff muscles is best performed by isolating each muscle group and selectively training that muscle
  • If strengthening and stretching does not help over time, surgery may be the best option for the injury.

Prevention
  • Before an exercise, stretching and warming up the muscle group will ensure a safe workout. 
  • Strengthening the muscles using specific and targeted exercises for a particular muscle group will benefit dramatically
  • If symptoms begin to arise, early evaluation and treatment is the best bet
  • Catching mild inflammation can prevent it from becoming rotator impingement, tendinosis, or a complete tear of the cuff
  • Stretching and strengthening is ideal for this type of situation.

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Rotator Cuff Tear

Pathology

  

  • Rotator cuff tears involve the tearing of one of the four muscles that make up the rotator cuff;  supraspinatus, infraspinatus, subscapularis, and teres minor

 

  • The most common site of tearing occurs in the supraspinatus muscle

  

Etiology

  • Caused by trauma or repetitive overhead work or activity

     

  • Occurs in conjunction with another injury such as a dislocation or fracture

     

  • Swimmers, tennis players, and pitchers are succeptible to tearing of the rotator cuff

Signs and Symptoms

  • Severe pain when performing over-head activities

     

  • Pain over the deltoid muscle

     

  • Shoulder may feel weak

     

  • Clicking, snapping or popping sound followed by weakness and pain

     

  • May feel like a broken clavicle        

 
                                    Treatment                                 

 

  • Rest and limited overhead activity

     

  • Use of a sling

     

  • NSAIDS

     

  • Physical therapy to strengthen the muscles

     

  • Electrical stimulation 

     

  • Ultrasound or a Cortisone injection

     

  • Surgery to repair tendon

     

    (source: http://orthoinfo.aaos.org)

 

 

 

 

 
Rotator Cuff Tendinitis
Pathology

  • Rotator cuff tendinitis involves the inflammation of the tendons of the rotator cuff 

  • The supraspinatus muscle is the most susceptible to tendinitis

Etiology

  • Tendinitis of the rotator cuff can be caused by muscle imbalance in the glenohumeral rotators, loose glenohumeral joint capsule, poor control of scapular movement and impingement (see above). 

  • The acromion angle plays a significant role in predisposing patients to tendinitis when its angle is less than 70 degrees (Starkey & Ryan 2002).

Signs and Symptoms
    • Severe pain is felt when the arm is lifted into overhead position
    • There is tenderness over the outside of the shoulder joint
    • Weakness may occur in the arm, at least partly related to pain
    • Pain may radiate into the arm and into the neck
      (Source: www.myelectronicmd.com)

Special Tests
  • Empty Can Test(video)
  • Drop Arm Test(video)

     

    		•

    Treatment
    • Rest or immobilization of the affected tendons is helpful for recovery. This may be achieved using a splint or a removable brace. 
    • The application of heat or cold to the affected area can help.
    • Non-steroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, can also reduce both pain and inflammation. 
    • Steroid injections into the tendon sheath can also be very useful in controlling pain and allowing physical therapy to start.
    • Physical therapy that stretches and strengthens the muscle and tendon is essential. This can restore the tendon's ability to function properly, improve healing, and prevent future injury.
    • Rarely, surgery is needed to physically remove the inflammatory tissue from around the tendon.

     

    (Source: http://adam.about.com/encyclopedia/infectiousdiseases/Tendinitis.htm)

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    Bicepital Tendinitis

     

    Pathology

    • Bicepital tendinitis when the tendon of the long head of the biceps is displaced from the biciptal groove in the humerus

       

    • Subluxation is most common when the elbow is flexed and the humerus is externally rotated

    Etiology
    • Biceptial tendinitis is can be caused by overuse of the biceps brachii muscle, rotator cuff dysfunction, or because of impingment (discussed above) 

    • The transverse humeral ligament is responsible for holding the tendon of the long head of the biceps within the bicipital groove. 

    • When this ligament is torn or overstretched it may not form this function properly (Starkey & Ryan 2002)

    Signs and Symptoms
    • Pain when the arm is overhead or bent.
    • Localized tenderness as the tendon passes over the groove in the upper arm bone. 
    • Occasionally, a snapping sound or sensation in the shoulder area

    (Source: orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=209)

    Special Tests

    Treatment
    • Rest or immobilization (splint or removeable brace) of the affected tendons is helpful for recovery

    • The application of heat or cold to the affected area can help

    • Non-steroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, can also reduce both pain and inflammation

    • Steroid injections into the tendon sheath can also be very useful in controlling pain and allowing physical therapy to start

    • Physical therapy that stretches and strengthens the muscle and tendon is essential. This can restore the tendon's ability to function properly, improve healing, and prevent future injury.

    • Surgery (rarely) is needed to physically remove the inflammatory tissue from around the tendon.
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    Superior Labrum Anteroposterior Lesions (SLAP)

     

    Pathology
    • A superior labrum anteroposterior (SLAP) lesions involves the detachment of the superior portion of the labrum inside the glenohumeral joint near the tendon of the long head of the biceps

     

     

     

     

    (Source: www.wheelessonline.com/ortho/superior_glenoid_labrum_lesions_slap)

     

    Type

    Description

    Treatment

    I

    - fraying and degeneration of the superior labrum, normal biceps (no detachment);
    - most common type of SLAP tear (75% of SLAP tears);
    - often associated with rotator cuff tears;

    - debridement (surgery)

    II

    - detachment of superior labrum and biceps insertion from the supra-glenoid tuberlce; 
    - when traction is applied to the biceps, the labrum arches away from the glenoid; 
    - typically the superior and middle glenohumeral ligaments are unstable;

    - anatomic arthroscopic repair (surgery)

    III

    - bucket handle type tear; 
    - biceps anchor is intact;

    - anatomic arthroscopic repair (surgery)

    IV

    		 - vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps (intrasubstance tear); - may be treated w/ biceps tenodesis if more than 50% of the tendon is involved
    		 

    Etiology

    Signs and Symptoms

     

    • Complaints of pain at the shoulder
    • Clicking sounds within the shoulder during mobilization
    • A feeling of instability in the shoulder.

    (Source: http://www.myorthodoc.com/Shoulder_labral_injuries.htm) 

     

    Special Tests

    Treatment

    (see chart above)

     Back To Top

     

     

    Thoracic Outlet Syndrome

     

     

     

    Pathology
    • The thoracic outlet is a space allowing the passage of the trunks and medial cord of the brachial plexus, subclavian artery and vein is critical to the correct function of these nerves and vessels. 

    • Any impingment between the clavicle and first rib, pectoralis minor and rib cage, or anterior and middle scalenes can contribute. 

    • Thoracic outlet syndrome (TOS) occurs when there is not enough space in these areas resulting in pressure on these structures causing dysfunction and discomfort (Starkey & Ryan 2002).

    Etiology
    • TOS could be caused by a variety of factors including injury, disease or congenital abnormality that would cause compression or blockage of the thoracic outlet
    • Obesity, poor posture, prolonged anterior pressure, acute trauma or repetitive overhead activities can contributie to TOS 

    • In particular, the presence of a cervical rib can cause TOS, but only 10% of the population with a cervical rib has TOS

    (Starkey & Ryan 2002)

    Signs and Symptoms

    Special Tests

    Treatment

    The treatment for TOS is conservative, and does not usually involve surgery. 

     

    • Physical therapy can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone.
    • Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.
    • Nonsteroidal anti-inflammatory drugs, like aspirin or ibuprofen, can ease the pain.
    • If you are overweight, your physician may recommend that you go on a diet.
    • You may need to change your workstation and avoid strenuous activities.
    • In rare cases, surgery may be recommended if conservative treatment fails. The surgery involves dividing a muscle in the neck and removing a portion of the first rib.

      (Source: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=206)

    Prevention

    If you have symptoms of TOS, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the thoracic outlet. You could also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try; do 10 repetitions of each exercise twice daily.

     

    1. Corner Stretch: Stand in a corner (about one foot away from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.

     

    2. Neck Stretch: Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.

     

    3. Shoulder Rolls: Shrug your shoulders up, back, and then down in a circular motion.

     

    4. Neck Retraction: Pull your head straight back, keeping your jaw level. Hold for 5 seconds.

     

     (Source: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=206)
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    REFERENCES

     

    Starkey C, Ryan J.  Evaluation of Orthopedic and Athletic Injuries 2nd Edition. F.A. Davis Company 2002.

     


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    • Recent comments:
      Marcy  Connell:p.s. I didn't know how to add that section (rotator cuff tearing) into the links at the top....if anyone can do that for me, that'd be great!
      marcy connell:I added the section about rotator cuff tearing. It kind of goes hand in hand with the other pathologies, but in doing research on shoulder pathologies, rotator cuff tears seemed to appear often.
      Brodie:I liked the info about shoulder impingement causes, so I added a few pics and descriptions of irregularly shaped acromion.
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