I had an interesting rotator cuff injury case this week. A young male with a long period of shoulder pain that had got worse in the last six months. On his in take form was a surgery from last october. He had the surgery as a last result to give him some relief. The surgery had given him some short-term relief but not long-lasting. The operation was to shave some of the bone around his ac joint and a excision. Prior to his surgery my client had several injections with only little to no relief. On his consultation with me there were no obvious signs of trauma or impact that could have been the cause to the presenting problem but his main complaint was lifting work goods above his head which would aggravate his pain.
On examination i found limited over head movements like lifting house hold goods into cupboards. Bringing his arm away from his body would also cause pain when getting to 90 degrees. when rotating his arm around his back to put his jacket on would also cause him really bad pain. sleeping on that side of his shoulder would also cause that same pain he presentted with.
On my further testing I found several of his shoulder muscles to be very under active. I found his surpraspinatus muscle over working for his middle deltoid muscle. releasing the supraspinatus muscle helped strengthen the deltoid muscle. I also found his medial inner shoulder muscle ( Subscapularis) under active and his opposite (Infraspinatus) over working. On releasing the over working muscle it helped strengthen the inner shoulder muscle and bring down the initial presenting pain
After every session has finished I assign a home care plan to meet the individual needs and build on the progress they have made in the session.
As sports injury therapists we regularly assess and treat patients and athletes with shoulder injury and pain. It has been suggested that shoulder injury and pain can effect up to 2% of the general population. However, we know that posterior shoulder instability is much less common accounting for somewhere between 2 and 10% of these cases. The reason why it is important for use is that these presentations are most common in athletes, secondary to either overuse or a traumatic episode. This makes knowledge of evidence based management and diagnosis of posterior shoulder injury and pain particularly pertinent.
Whilst I never labour the anatomy too much, as it should pretty well be general knowledge, here is a quick run down.
The static stabilizers of the posterior shoulder are:
Posterior Shoulder Capsule
Posterior shoulder Ligaments (with their labral attachments): most importantly the posterior band of the inferior shoulder ligament.
The anterior stabilizers of the shoulder (including anterior GH ligaments and capsule) will also prevent excessive posterior translation of the humerus.
The dynamic stabilizers of the posterior shoulder are:
Dynamic stability is provided through the mechanisms of “scapulohumeral balance” and “concavity compression” (Lippit & Matsen, 1993).
Classification of Posterior Shoulder injury and pain
Hawkins and McCormack (1988) divided patients with posterior shoulder instability into 3 categories:
Acute Posterior Dislocation
Chronic Posterior Dislocation (which is fixed or locked)
Recurrent Posterior Subluxation
The majority of the patients/athletes that you see would likely fit nicely into category 1 or 3. However, we know that posterior shoulder instability can come in many forms. It is usually seen as a component of the following:
Unidirectional (pure posterior instability)
Bidirectional (both posterior and inferior)
Multidirectional (which includes anterior, inferior and posterior: think AMBRI instability).
Assessment of Posterior Shoulder injury and pain
It is important to maintain a high index of clinical suspicion in these cases, as it has been suggested that up to 50% of posterior shoulder dislocations are misdiagnosed on initial medical consultation. There are some sports or athletic pursuits in which posterior shoulder instability is more common. If you work with these athletes, you will encounter posterior shoulder instability in your career. The athletes of the following sports are at risk
Overhead throwers e.g. pitchers
The athlete will often report:
Mechanism: similar to that discussed in “Pathogenesis” above
Pain: aching pain along posterior joint line, superior shoulder, or biceps area
“Weakness” may be perceived by the athlete
Shoulder injury Physical Examination
ROM will depend on the extent of damage, chronicity and nature of instability (dislocation vs. subluxation)
Concomitant rotator cuff tears are uncommon but should be excluded.
Likely that flexion, adduction and internal rotation will be painful.
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