Shoulder

&
related pathologies

Dr. Adil Ali Ansari (PT)

Ball & Socket type

• High ROM
• Less Stability

Complex of:
• Clavicle
• Scapula
• Humerus

Surrounded by anterior &

posterior musculatures
Which muscle is not included under rotator cuff muscles:
1. Supraspinatus
2. Infraspinatus
3. Teres Major
4. Teres Minor

Which of the following muscle is responsible for abducting the

arm during initial 0 to 30 degrees: The muscle that assists in shoulder extension,
1. Infraspinatus adduction, and medial rotation is:
2. Deltoid A) Pectoralis Major
3. Supraspinatus B) Trapezius
4. None of the above C) Latissimus Dorsi
D) Deltoid
 Introduction

The shoulder is composed of 3 Synovial

Joints:

1) The Glenohumeral joint (GH)

2) The Acromioclavicular joint (AC)
3) The Sternoclavicular joint ( SC)

The scapulothoracic joint also functions as joints in the

shoulder complex.
STERNOCLAVICULAR JOINT

SC joint is a plane synovial joint

consists of two saddle-shaped surfaces, one at the

sternal or medial end of the clavicle and one at the notch
formed by the manubrium of the sternum and first costal
cartilage.
• 3 rotatory degrees of freedom:
• Elevation/depression
• Protraction/retraction
• Anterior /posterior rotation of clavicle

• 3 degrees of translatory motion at the SC joint

• (very small in magnitude):
• Anterior /posterior
• Medial/lateral
• Superior /inferior
Acromioclavicular
Joint
• Plane synovial joint

• 3 rotational and 3 translational

degrees of freedom

• The primary function of the AC joint is

to allow the scapula additional range of
rotation on the thorax and allow for
adjustments of the scapula

• allows transmission of forces from the

upper extremity to the clavicle.
• The capsule of the AC joint is weak and cannot
maintain integrity of the joint without reinforcement of
the superior and inferior acromioclavicular and the
coracoclavicular ligaments.

• reinforced by aponeurotic extensions from deltoid

and trapezius.
Glenohumeral (GH) Joint
Osteokinematics

• Flexion / extension
• Abduction / Adduction
• Medial / Lateral rotation

Arthrokinematics

• Spin (pure flexion and extension)

• Inferior slide (Abduction)
• Superior slide (Adduction)
• Posterior slide (Medial rotation)
• Anterior slide (Lateral rotation)
• If concave surface is moving on a
stationary convex surface, gliding
will occur in the same direction as
the rolling motion

• If a convex surface is moving on

a stationary concave surface,
gliding will occur in opposite
direction to rolling
Scapulo-humeral Rhythm
1:2
 Setting
Phase

Total ROM – 30 + 40 + 20 = 90

Second
Phase
Final Phase GH Role
• Setting – 30
• Second – 40
• Final – 60
Total @ GH - 130
Scapula Role
• Setting – 0
• Second – 20
• Final – 30
Total @ Scapula - 50

Total ROM – 130 + 50 = 180

• Which of the following muscles plays a critical role in
maintaining proper dynamic stability of the shoulder
joint by compressing the humeral head into the glenoid
fossa during arm elevation?

• a) Teres major
• b) Subscapularis
• c) Pectoralis major
• d) Latissimus dorsi
Common Pathologies
&
Injuries
Freezing

Frozen
Glycation: High blood sugar levels in diabetes can lead to a
process called glycation, where sugar molecules attach to
proteins. This can affect the flexibility and function of joint
tissues, potentially contributing to the development of frozen
shoulder.

In diabetes, high blood glucose levels can lead to the

formation of advanced glycation end products
(AGEs). These molecules can accumulate in joint
tissues, including the shoulder capsule, causing
cross-linking of collagen fibers. This process may lead
to increased stiffness and reduced range of motion in
the joint, characteristic of frozen shoulder.
Codman's paradox is a term used to describe a
seemingly contradictory phenomenon that can
occur in individuals with frozen shoulder
(adhesive capsulitis). It refers to the observation
that some patients with frozen shoulder
experience relief from their pain and increased
range of motion during passive motion of the
affected shoulder while they are under general
anesthesia or asleep.

The paradox lies in the fact that when awake

and conscious, individuals with frozen shoulder
often experience significant pain and restricted
range of motion during any attempt to move
their shoulder actively. However, when the same
shoulder is moved passively (by an external
force) while the person is asleep or under
anesthesia, there is a remarkable improvement
in the range of motion, and they may not
experience the same level of pain.
 Which of the following special test will
be positive for a 70 year old patient
with frozen shoulder?

a) Drop Arm Test

b) Hawkin’s Kennedy
c) All of the above
d) None

Which of the following medical conditions is often associated

with an increased risk of developing frozen shoulder?
a) Osteoporosis
b) Hypertension (high blood pressure)
c) Diabetes
d) Migraines
 Adducted

Global Restriction
Rohit Sharma dislocate his shoulder during 2nd ODI

Pops it back
Shoulder laxity is a significant risk factor for shoulder
dislocation. The looser the ligaments and capsule,
the easier it is for the humerus to slip out of its
socket. People with shoulder laxity are more prone
to shoulder dislocations, especially with repetitive
stress or trauma.
Bankart lesions are injuries of the anteroinferior
aspect of the glenoid labral complex.

Soft Bankart lesion: labrum tears from the glenoid,

and the injury involves only the soft tissue. Most
common

Bony Bankart lesion: labrum tears and a part of the

bony glenoid fractures or breaks off. May lead to
notable bone loss in the glenoid, a cause chronic
instability.

In many cases of anterior dislocation patients have a

Bankart lesion. A reverse Bankart lesion can occurs
in case of a posterior dislocation.
What is Glenohumeral Arthritis?

Glenohumeral arthritis is a degenerative condition affecting

the glenohumeral joint, which is the ball-and-socket joint of
the shoulder where the head of the humerus (upper arm
bone) fits into the glenoid cavity of the scapula (shoulder
blade).

This condition involves the wearing down of the articular

cartilage that covers the surfaces of these bones, leading to
pain, stiffness, and reduced range of motion.
 Common symptoms of glenohumeral arthritis include:
Glenohumeral arthritis can be classified into:
• Persistent shoulder pain, especially with movement
• Primary Osteoarthritis: Degenerative joint • Stiffness and reduced range of motion
disease without an identifiable cause. • Swelling and tenderness around the joint
• Grinding or clicking sensations (crepitus) during shoulder
• Secondary Osteoarthritis: Due to a movement
specific cause such as trauma, • Weakness in the shoulder muscles
inflammation, or metabolic conditions.

• Inflammatory Arthritis: Includes

rheumatoid arthritis and other
autoimmune conditions.

• Post-Traumatic Arthritis: Following an

injury or surgery.

• Cuff Tear Arthropathy: Associated with

massive rotator cuff tears.
Facts about Glenohumeral Arthritis

Prevalence: Approximately 4% of adults over the

age of 60 have symptomatic glenohumeral
arthritis.

Gender Differences: While primary osteoarthritis

affects both genders equally, rheumatoid arthritis
is more common in women.

Age Factor: The risk of developing glenohumeral

arthritis increases significantly with age.
Burners (Stingers) Syndrome

common injury in contact sports and reflects an upper cervical

root injury or a peripheral nerve dysfunction injury. It is a
transient nerve injury which occurs following over-stretching of
the upper trunk of the brachial plexus or compression of the
C5/C6 nerve root, depending on the mechanism of injury.

Classification of Peripheral Nerve Injuries

• Grade I- Neuropraxia; a disruption of nerve function

involving demyelination. Axonal integrity is preserved, and
remyelination follows within three weeks.

• Grade II- Axonotmesis; in which axonal damage and

Wallerian degeneration occur.

• Grade III- Neurotmesis; complete nerve transection

(neurotmesis), or permanent nerve damage.
A forceful blow causing depression of the shoulder and lateral flexion of the neck to the contralateral side,
leading to traction of the upper roots of the brachial plexus.

A direct blow to supraclavicular fossa or Erb’s point causing a percussive injury.

Compression of nerve roots or brachial plexus when the head is forced into hyperextension and ipsilateral
side flexion towards the side of trauma.
• The term “Impingement
Syndrome” was popularized
by Charles Neer in 1972
• Neer defined impingement
as pathologically
compression of rotator cuff
against the anterior
structure of coracoacromial
arch, anterior 1/3 of the
acromion, coraco-acromial
ligament & AC joint.
• Impingement causes Mechanical irritation of cuff
tendons - resulting in haemorrhage and swelling
(commonly known as tendonitis of rotator cuff)
– The supraspinatus muscle is usually involved.
• This also affect the bursa – resulting in bursitis.
• Shoulder complex is susceptible to impingement
injuries from overhead sports –
– Such as baseball, tennis, swimming, volleyball etc.
• Impingement with rotator-cuff tendonitis is one of
most common shoulder injuries seen in athletes.
 Signs and Symptoms

• Pain & tenderness in the gleno-humeral area

• Pain or weakness with active abd in midrange
• Limited internal rotation compared to normal side
• Confirmation with special tests (Hawkins / Neer’s
impingement test)
• Tenderness to palpation in the sub-acromial area

57
 ETIOLOGY OF IMPINGEMENT

External Internal (Glenoid)

Functional
Repetitive
Primary Secondary Trauma

Structural
Outlet
Obstruction Instability Instability

Rotator Cuff Rotator Cuff Rotator Cuff

Dysfunction & Dysfunction Dysfunction
type of acromion
Ratan Khuman (MPT Ortho & Sports) 7/27/2013
Types of acromions

59
Scapular Dyskinesis
What is the primary cause of shoulder impingement
syndrome?
a) Torn labrum
b) Glenohumeral instability
c) Rotator cuff tendinopathy
d) Bicipital tendon rupture
• Patient’s Needs : Individuality to treatment
Prescription as per individual patient (Age, Gender, Lifestyle)

• Patient’s current level of functioning

• Pathology Phases division :

Inflammatory (1) > Healing (2) > Back to work (3) > Specific Sports (4)

• Aims & Objectives to achieve phase wise:

❑Inflammatory :
⮚Less Scope of vigorous Exercises
⮚Reduce Inflammation & Swelling
⮚Focus on maintain available ROM
❑Healing :
⮚Focus on < inflammation
⮚Maintain ROM + Passive ROM ex
⮚Isometric Contractions
⮚Pain regulation
PHASE 1
❑Back to work: PHASE 2
⮚Gain max. ROM
⮚Strengthening via static + dynamic ex PHASE 3
⮚Pain regulation
⮚Muscle Re-education PHASE 4
❑Sports Specific Activities:
⮚Advance Strengthening
⮚Training
• Time duration per phase: Individual to patients
(1 : 1 to 2 weeks, 2: 3 to 4 weeks, 3: 3 to 4 weeks, 4 :
2 to 4 weeks)

Exercise Prescription & Manual Therapy :

⮚Specific to target area or muscle
⮚Use isometric + dynamic combinations as per
requirements
⮚Use the FITT regime :
• Frequency
• Intensity
• Time
• Type
⮚Take patient’s input max. number of times
⮚Demonstrate instead of instruct