Shoulder

Risk Factors:

1. Trauma: High-impact injuries, such as falls, sports injuries, or accidents.
2. Repetitive Overuse: Activities that involve repetitive shoulder movements, such as swimming or throwing sports.
3. Genetics: Hyperlaxity, 
4. Previous Dislocation: A history of shoulder dislocation increases the risk of future dislocations.

Types of Shoulder Instability

1. Traumatic Anterior Shoulder Instability:

• Cause: Typically caused by an acute injury, such as a fall or collision, leading to a dislocation.
• Symptoms: Pain, inability to move the shoulder, visible deformity.
• Treatment: Often requires reduction (repositioning), followed by physical therapy or surgery.

2. Atraumatic Shoulder Instability:

• Cause: Repetitive overhead activities or congenital laxity (loose joints).
• Symptoms: Feeling of shoulder slipping out of place, discomfort, weakness.
• Treatment: Physical therapy to strengthen muscles; surgery may be necessary for severe cases.

3. Multidirectional Instability (MDI):

• Cause: Genetic predisposition, generalized ligamentous laxity, or repetitive overuse.
• Symptoms: Instability in multiple directions (anterior, posterior, inferior), generalized shoulder pain, frequent subluxations.
• Treatment: Conservative management with physical therapy focused on strengthening and stabilizing exercises; surgery in refractory cases.

4. Posterior Shoulder Instability:

• Cause: Less common, often due to repetitive stress or trauma.
• Symptoms: Pain, clicking, or a feeling of the shoulder slipping backward.
• Treatment: Physical therapy and rehabilitation; surgery for chronic or severe instability.

1. Clinical Examination:

   - Patient history: Includes details about the injury mechanism, previous dislocations, and symptoms.

   - Physical examination: Tests to assess shoulder range of motion, strength, and stability (e.g., apprehension test, relocation test).

2. Imaging:

   - X-rays: To rule out fractures and assess the position of the humerus.

   - MRI or MR Arthrogram: To evaluate soft tissue structures, such as the labrum, ligaments, and rotator cuff.

   - CT scan with 3D reconstruction: For detailed bone assessment, and assess for glenoid bone loss, especially if there is suspicion of bony defects or fractures.

Operative Treatment:

1. Arthroscopic Surgery: Minimally invasive surgery to repair torn or stretched ligaments and the labrum. Common procedures include:

   - Bankart Repair: Reattaching the torn labrum to the glenoid.

   - Capsular Shift: Tightening the joint capsule to prevent excessive movement.

 

2. Open Surgery: May be necessary for complex or recurrent dislocations. Procedures include:

   - Latarjet Procedure: Transferring a piece of bone with an attached tendon to the front of the glenoid to provide additional stability.

   - Glenoid reconstruction: for recurrent, chronic instability with significant bone loss

Postoperative Restrictions and Outcomes:

   - Immobilization: The shoulder is usually immobilized in a sling for a few weeks post-surgery.

   - Physical Therapy: Gradual rehabilitation program starting with passive range of motion exercises, progressing to active and strengthening exercises.

   -Activity Restrictions: Avoidance of overhead activities, heavy lifting, and contact sports for several months.

 

Rotator Cuff Tears 

Rotator cuff tears involve damage to one or more of the four muscles and tendons that stabilize the shoulder joint and enable a wide range of shoulder movements. 

How do rotator cuff injuries occur?

• Acute Injury: Sudden, severe injuries such as falling on an outstretched arm or lifting something heavy.
• Chronic Degeneration: Wear and tear over time, particularly common in older adults (50+)

Risk Factors:

• Age (more common in people over 40)
• Repetitive overhead activities (e.g., athletes, painters)
• Family history of rotator cuff injuries
• Poor posture and shoulder mechanics

Types of Rotator Cuff Tears:

1. Partial Tear: Damage but not complete severance of the tendon.
2. Full-Thickness Tear: Complete tear through the tendon.

Diagnosis

• Clinical Exam: 
• Evaluation of shoulder pain, weakness, and range of motion. Assessment of shoulder stability and function through patient history and symptom description.
• Physical examination: Tests to assess shoulder range of motion, strength, and stability (e.g., Jobe’s test, Belly press test, Bear hug test)
• Imaging: 
• XR- Useful for initial assessment and ruling out bone-related causes of shoulder pain, however, it is unable to visualize soft tissue structures directly.
• MRI- Provides detailed visualization of the rotator cuff and other soft tissues, making it the preferred method for confirming and characterizing rotator cuff tears. 

Treatment Options:

• Nonsurgical:
• Rest and activity modification
• Physical therapy
• Anti-inflammatory medications (NSAIDs),
• Corticosteroid injections
• Surgical:
• Arthroscopic Repair: Minimally invasive, using small portal incisions, most rotator cuff repairs are performed this way.
• Open Repair: Traditional surgery with a larger incision, usually reserved for large or complex tears, if there is significant tendon retraction, or revisions of previous repairs.
• Mini-Open Repair: Combination of arthroscopy and open surgery.

Surgical vs. Conservative Treatment:

• Nonsurgical, conservative treatment may be sufficient for minor or partial tears. 
• Surgical treatment is often recommended for complete tears, severe pain and limitation in activities, or when nonsurgical methods fail.

Postoperative Plan/Restrictions:

• Initial Phase (0-6 weeks): Immobilization in a sling, passive range of motion exercises.
• Intermediate Phase (6-12 weeks): Active range of motion and strengthening exercises.
• Advanced Phase (3-6 months): Gradual return to normal activities, advanced strengthening.
• Full Recovery (6-12 months): Complete return to sports or heavy lifting.

 

SLAP Tears

SLAP (Superior Labrum Anterior-Posterior) tears are injuries to the superior part of the labrum in the shoulder, where the biceps tendon attaches.

How Do They Happen?

• Acute trauma (e.g., falling on an outstretched arm, a direct blow to the shoulder)
• Repetitive overhead activities (e.g., throwing sports, lifting)

Risk Factors:

• Overhead athletes (e.g., baseball pitchers, tennis players)
• Previous shoulder injuries
• Age-related degeneration

Types of SLAP Tears:

• Type I: Fraying of the labrum, attached biceps
• Type II: Detachment of the superior labrum and biceps
• Type III: Bucket-handle tear of the labrum, intact biceps
• Type IV: Bucket-handle tear extending into the biceps tendon
• Types V-X: Variations involving other parts of the labrum and capsule

Diagnosis/Imaging:

• Physical Exam: O'Brien’s test, crank test, and biceps load test.
• Imaging: MRI or MR arthrogram to visualize the labrum and associated structures.

Treatment Options:

• Nonsurgical:
• Rest, physical therapy focusing on strengthening the rotator cuff and scapular stabilizers, and anti-inflammatory medications.
• Steroid injections in some cases.
• Surgical:
• Arthroscopic debridement or repair, especially for younger patients or those with persistent symptoms.
• Type II and Type IV tears often require surgical repair.

Surgical vs. Nonsurgical:

• Nonsurgical management is often preferred for older patients or those with degenerative tears.
• Surgical intervention is typically chosen for younger, active patients, especially athletes, or those who do not respond to conservative treatment.

Postoperative Plan/Restrictions:

• Initial Phase (0-6 weeks): Immobilization with a sling, passive range of motion exercises.
• Intermediate Phase (6-12 weeks): Gradual increase in range of motion, gentle strengthening exercises.
• Advanced Phase (3-6 months): Progressive strengthening, return to functional activities.
• Full Recovery: Usually takes 4-6 months, with a gradual return to sports or heavy lifting based on functional recovery and physician clearance.

Proximal Biceps Tendinitis and Tendinopathy 

Biceps tendonitis is inflammation or degeneration (tendinopathy) of the tendon connecting the biceps muscle to the shoulder, particularly in the bicipital groove.

How Does It Occur?

• Due to repetitive overhead activities, trauma, or degeneration from overuse.

Risk Factors:

• Overhead athletes (e.g., baseball players, swimmers)
• Older age
• Repetitive shoulder use
• Associated shoulder pathologies (e.g., rotator cuff tears)

Diagnosis/Imaging:

• Physical examination (Speed's test, Yergason's test)
• Imaging: 
• Ultrasound: Can detect tendon inflammation, thickening, and partial tears.
• MRI: Provides detailed images of the soft tissues, revealing inflammation, degeneration, or tears of the tendon.
• X-rays: Although not as useful for soft tissues, they can identify bony abnormalities or calcifications associated with tendinitis.

Treatment Options:

• Nonsurgical:
• Rest: Avoid activities that exacerbate symptoms.
• Physical Therapy: Focus on stretching and strengthening exercises to improve shoulder mechanics and reduce pain.
• NSAIDs: Nonsteroidal anti-inflammatory drugs to reduce pain and inflammation.
• Corticosteroid Injections: Bicipital groove corticosteroid injections can provide temporary relief from inflammation and pain.
• Surgical: Indicated for severe or persistent cases that do not respond to nonsurgical treatment:
• Debridement: Removal of damaged tissue.
• Biceps Tenotomy: Cutting the tendon to relieve tension and pain.
• Biceps Tenodesis: Reattachment of the tendon to a different location to relieve symptoms and improve function.

Postoperative Plan/Restrictions:

• Initial Phase (0-6 weeks): Immobilization with a sling, passive range of motion exercises.

• Intermediate Phase (6-12 weeks): Gradual increase in range of motion, gentle strengthening exercises.

• Advanced Phase (3-6 months): Progressive strengthening, return to functional activities.
• Full Recovery: Usually takes several months, with activity restrictions based on the type of surgery performed and the patient’s recovery progress.

Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis, or frozen shoulder, is an inflammatory condition characterized by shoulder stiffness, pain, and significant loss of passive range of motion.

How Does It Occur?

• It occurs due to inflammation within the joint capsule, leading to fibrosis and adhesions. It can be primary (idiopathic) or secondary (due to trauma, surgery, or immobilization).

Risk Factors:

• Diabetes mellitus
• Thyroid disease 
• Hypertriglyceridemia
• Cervical spondylosis 
• Female gender 

Diagnosis:

• Primarily clinical, based on history and physical examination, and evaluating stiffness. 
• Imaging:
• X-rays: Rule out other conditions.
• MRI: May show thickening of the capsule and other characteristic findings.
• Ultrasound: Can detect associated rotator cuff pathology.

Treatment Options:

• Nonsurgical:
• Medications: NSAIDs, calcitonin, losartan, for pain relief. 
• Physical Therapy: Gentle range of motion exercises, stretching, and graded resistance training.
• Corticosteroids: Intra-articular injections for pain relief and improved range of motion.
• Anti-inflammatory Diet Modifications: 
• Surgical: 
• Manipulation Under Anesthesia: For refractory cases.
• Capsular Release: Arthroscopic procedure for severe cases not responding to conservative treatment

References: 

https://www.ncbi.nlm.nih.gov/books/NBK547664/

https://www.ncbi.nlm.nih.gov/books/NBK532955/

https://www.ncbi.nlm.nih.gov/books/NBK538284/

https://www.ncbi.nlm.nih.gov/books/NBK507847/

https://www.ncbi.nlm.nih.gov/books/NBK533002/