The shoulder that won’t get better….
Dr Chris Bradshaw Sports Physician
www.puresportsmed.com
Parkside Hospital Wimbledon Cromwell Road Kensington
Shoulder Injuries
Acute Chronic
Acute shoulder injuries
Instability Labral pathology (SLAP lesions) Fractures (clavicle, scapula, humerus) A/C joint injuries Rotator cuff tears Tendon ruptures (biceps, pectoralis major)
Chronic shoulder injuries
Impingement syndromes
(including subacromial pathology)
Labral pathology Laxity in the throwing athlete Rotator cuff pathology Referred pain
Others (Zebras and normal horses)
Making sense of impingement
Anatomical abnormalities (e.g. beaked acromion) Poor scapular control Anterior instability Excessive load on rotator cuff muscles
Encroachment from above
Inferior movement of acromion
Anterosuperior translation of humeral head
Rotator cuff weakness
Narrowing of subacromial space Impingement with exercise Rotator cuff tendinitis
Imbalance between humeral head elevators and depressors Swelling of rotator cuff tendon Elevation of humeral head
Overuse Instability Abnormal biomechanics Posterior capsule tightness
Making sense of impingement
If the impingement won’t get better……….
Anatomical
encroachment from above
If the impingement won’t get better……….
Scapular stability
Causes of poor scapulothoracic rhythm
Long thoracic nerve
palsy
Brachial plexopathies
If the impingement won’t get better……….
Anterior humeral
translation
Think about
posterior capsular tightness
Capsular restrictions
End stage “frozen
shoulder”
Aetiology uncertain Associated with
diabetes, heart disease
Females more common Night ache
Capsular restrictions
Sporting population usually
subtle and minimal
Night ache
Pain with end range
activities
Capsular restrictions
Decreased range of motion
- especially end abduction,
internal rotation and horizontal flexion
Relocation test positive
AP glide sensitive
Capsular restrictions treatment
Don’t like being
mobilised
Corticosteroid injection Hydrodilatation If all else
fails….arthroscopic capsular release
Capsular restrictions
Still need best
practice rehabilitation after hydrodilatation or arthroscopic treatment
If the impingement won’t get better……….
Rotator cuff function
(Remember rotator cuff tears)
Rotator cuff dysfunction suprascapular nerve entrapment
Anatomy
Suprascapular nerve entrapment
Chronic rotator cuff
weakness…often presents as an impingement
Sometimes exercise
induced pain
Common in
volleyball
Suprascapular nerve entrapment treatment
Conservative
- massage - Neuromeningeal - Cervical spine
Suprascapular nerve entrapment treatment
surgery
Bony pathology
Osteolysis
Stress fractures
others
Osteolysis distal clavicle
Common in weight-
lifters (bench press)
Chronic A/C joint
pain
Tender distal clavicle Increased uptake on
bone scan
Osteolysis distal clavicle treatment
Physiotherapy
Corticosteroid
injection
surgery
Stress Fractures
Coracoid process
(trap shooters)
Stress Fractures
1st rib – in ballet dancers
o o
Pain hard to localise Often thoracic or chest pain
o
Pain with coughing and
sneezing Local tenderness over 1st rib Pain with AP pressure centrally
o
o
1st rib stress fracture investigations
X-ray Bone scan
1st rib stress fracture
Technical issue in dancers
Related to anatomy
Usually settle with rest
(4-6 weeks)
Other bony pathology
Tumours
Osteoid osteoma
Young footballer – elite
Six month history of
shoulder pain
Night/rest ache Helped by aspirin Bone scan hot CT scan Pain relieved by
excision
Psoas
Very cool muscle
Anatomy well known
Intimately related to
diaphragm
Psoas
Vague shoulder pain Positive femoral
slump (with added ULTT)
Responds to manual
psoas release
Psoas
Treat with psoas
sheath injection
Why does it work?