SHOULDER PATHOLOGIES IN YOUNG ACTIVE PERSONS

VARIOUS SHOULDER PATHOLOGIES IN YOUNG ACTIVE INDIVIDUALS

1. COMMON SHOULDER PATHOLOGIES IN YOUNG ADULTS DR S.K.NAYAK SENIOR RESIDENT PHYSICAL MEDICINE AND REHABILITATION AIIMS RAIPUR(CG)

2. THREE CATEGORIES OF PATHOLOGIES INSTABILITY IMPINGEMENT ROTATOR CUFF INJURY

3. INSTABILITY - OCCURS WHEN LIGAMENTS, MUSCLES, AND TENDONS NO LONGER SECURE THE SHOULDER JOINT. IMPINGEMENT- OCCURS DUE TO THE FREQUENT ACTIVITIES LIKE EXCESSIVE, REPETITIVE AND HECTIC SHOULDER MOTIONS. ROTATOR CUFF INJURY- OCCURS IN ATHLETES PARTICIPATING IN REPETITIVE OVERHEAD SPORTS, INCLUDING SWIMMING AND TENNIS.

4. INSTABILITY

5. THE CLASSIFICATION OF GLENOHUMERAL JOINT INSTABILITY DEPENDS UPON THE DEGREE, FREQUENCY, ETIOLOGY, AND DIRECTION OF INSTABILITY. THE DEGREE OF INSTABILITY INCLUDES DISLOCATION, SUBLUXATION, MICROINSTABILITY.

6. A DISLOCATION IMPLIES THE HUMERAL HEAD IS DISSOCIATED FROM THE GLENOID FOSSA. A SUBLUXATION IMPLIES THE HUMERAL HEAD TRANSLATES TO THE EDGE OF THE GLENOID. MICROINSTABILITY IS ATTRIBUTABLE TO EXCESSIVE CAPSULAR LAXITY, AND IS MULTIDIRECTIONAL.

7. THE FREQUENCY OF INSTABILITY CAN BE ACUTE, CHRONIC . ACUTE INSTABILITY INVOLVES A NEW INJURY RESULTING IN SUBLUXATION OR DISLOCATION OF THE GLENOHUMERAL JOINT. CHRONIC INSTABILITY REFERS TO REPETITIVE INSTABILITY EPISODES.

8. ETIOLOGY OF INSTABILITY INCLUDES TRAUMATIC AND ATRAUMATIC . TRAUMATIC INSTABILITY- DISRUPTION OF THE GH JOINT. ATRAUMATIC INSTABILITY - CONGENITAL CAPSULAR LAXITY OR REPETITIVE MICROTRAUMA. VOLUNTARY AND INVOLUNTARY VOLUNTARY INSTABILITY REFERS TO AN INDIVIDUAL WHO VOLITIONALLY SUBLUXES OR DISLOCATES ITS GH JOINT, INVOLUNTARY INSTABILITY DO NOT PERFORM THIS. MOSTLY ASSOCIATED WITH PSYCHOLOGICAL PATHOLOGY.

9. INSTABILITY CAN BE UNIDIRECTIONAL OR MULTIDIRECTIONAL . UNIDIRECTIONAL REFERS TO INSTABILITY ONLY IN ONE DIRECTION. THE MOST COMMON IS TRAUMATIC ANTERIOR INSTABILITY. MULTIDIRECTIONAL IS INSTABILITY IN TWO OR MORE DIRECTIONS . USUALLY CAUSED BY CONGENITAL CAPSULAR LAXITY OR CHRONIC REPETITIVE MICRO TRAUMA.

10. TRAUMATIC ANTERIOR GLENOHUMERAL DISLOCATION FREQUENTLY TEARS THE ANTERIOR INFERIOR GLENOHUMERAL JOINT CAPSULE AND AVULSES THE ANTERIOR INFERIOR GLENOID LABRUM WITH OR WITHOUT SOME UNDERLYING BONE FROM THE GLENOID RIM - BANKART LESION . WITH A COMPRESSION FRACTURE OF THE POSTEROLATERAL ASPECT OF THE HUMERAL HEAD - HILL-SACHS DEFECT .

11. INFERIOR GLENOHUMERAL JOINT INSTABILITY TYPICALLY DOES NOT OCCUR IN ISOLATION. INCLUDES CAPSULO-LIGAMENTOUS LAXITY OR INJURY AND ABSENCE OF THE GLENOID FOSSA UPWARD TILT.

12. POSTERIOR GLENOHUMERAL JOINT INSTABILITY. CONGENITAL GLENOID HYPOPLASIA OR EXCESSIVE GLENOID OR HUMERAL RETROVERSION. HOWEVER, INCLUDES EXCESSIVE CAPSULO LIGAMENTOUS LAXITY OR INJURY, OR INJURY TO THE SUBSCAPULARIS TENDON.

13. A TEAR OF THE POSTERIOR INFERIOR GLENOID LABRUM CAUSING SEPARATION FROM THE GLENOID FOSSA RIM, OFTEN REFERRED TO AS A “REVERSE BANKART LESION,” OR A FRACTURE OF THE POSTERIOR INFERIOR GLENOID FOSSA RIM CAN ALSO CAUSE POSTERIOR GLENOHUMERAL JOINT INSTABILITY. A “REVERSE HILL-SACHS DEFECT” CAN ALSO BE PRESENT, WITH AN IMPACTION FRACTURE OF THE ANTERIOR HUMERAL HEAD.

14. ADHESIVE CAPSULITIS

15. ADHESIVE CAPSULITIS (COINED BY NEVIASER) , OR “FROZEN SHOULDER,” IS CHARACTERIZED BY PAINFUL, RESTRICTED SHOULDER ROM IN PATIENTS WITH NORMAL RADIOGRAPHS. 4 TIMES MORE COMMON IN WOMEN THAN MEN, AND IS MOST FREQUENTLY SEEN IN INDIVIDUALS BETWEEN 40 AND 60 YEARS OF AGE.

16. ADHESIVE CAPSULITIS IS USUALLY AN IDIOPATHIC CONDITION, BUT CAN BE ASSOCIATED WITH DIABETES MELLITUS, INFLAMMATORY ARTHRITIS, TRAUMA, PROLONGED IMMOBILIZATION, THYROID DISEASE, CEREBROVASCULAR ACCIDENT, MYOCARDIAL INFARCTION, OR AUTOIMMUNE DISEASE.

17. ADHESIVE CAPSULITIS HAS BEEN DIVIDED INTO FOUR STAGES STAGE 1 OCCURS FOR THE FIRST 1 TO 3 MONTHS AND INVOLVES PAIN WITH SHOULDER MOVEMENTS BUT NO SIGNIFICANT GLENOHUMERAL JOINT ROM RESTRICTION WHEN EXAMINED UNDER ANESTHESIA. STAGE 2 , THE “FREEZING STAGE,” FOR 3 TO 9 MONTHS AND ARE CHARACTERIZED BY PAIN WITH SHOULDER MOTION AND PROGRESSIVE GLENOHUMERAL JOINT ROM RESTRICTION IN FORWARD FLEXION, ABDUCTION, AND INTERNAL AND EXTERNAL ROTATION. STAGE 3 , “FROZEN STAGE,” PERSISTS FOR 9 TO 15 MONTHS AND INCLUDE A SIGNIFICANT REDUCTION IN PAIN WITH MAINTENANCE OF THE RESTRICTED GLENOHUMERAL JOINT ROM. STAGE 4 , “THAWING STAGE,” SYMPTOMS HAVE BEEN PRESENT FOR APPROXIMATELY 15 TO 24 MONTHS AND ROM GRADUALLY IMPROVES.

18. IMPINGEMENT

19. BIGLIANI ET AL FOUND A RELATION BETWEEN THE ACROMIAL SHAPE AND THE PRESENCE OF ROTATOR CUFF TEARS ON CADAVERIC EXAMINATION. HE CLASSIFIED THE ACROMIONS INTO THREE TYPES TYPE 1 ACROMIONS WERE RELATIVELY FLAT, WHEREAS TYPE 2 ACROMIONS DEMONSTRATED A CURVE, AND TYPE 3 ACROMIONS WERE HOOKED.

20. SUBACROMIAL, OR “OUTLET,” IMPINGEMENT CAN BE PRIMARY OR SECONDARY. CAUSATIVE FACTORS FOR PRIMARY IMPINGEMENT INCLUDE A HOOKED ACROMION OR A THICK CORACOACROMIAL LIGAMENT. SECONDARY IMPINGEMENT HAS MANY CAUSES, INCLUDING GLENOHUMERAL JOINT INSTABILITY, WEAK SCAPULAR STABILIZERS, SCAPULOTHORACIC DYSKINESIS, AND INSTABILITY.

21. ANOTHER FORM OF IMPINGEMENT, INTERNAL IMPINGEMENT , CAN OCCUR IN OVERHEAD ATHLETES, WHEN THE ARM IS ABDUCTED 90 DEGREES AND MAXIMALLY EXTERNALLY ROTATED. THERE IS CONTACT BETWEEN THE UNDERSURFACE OF THE ROTATOR CUFF AND THE POSTEROSUPERIOR GLENOID RIM. THE ANTERIOR APPREHENSION TEST CAN BE USED TO DETECT BOTH ANTERIOR INSTABILITY OF THE GLENOHUMERAL JOINT AND ALSO INTERNAL IMPINGEMENT. INTERNAL IMPINGEMENT CAUSES PATHOLOGIC CHANGES TO THE UNDERSURFACE OF THE ROTATOR CUFF.

22. ROTATOR CUFF TEARS

23. DEPALMA ET AL. DESCRIBED THE FREQUENCY OF ROTATOR CUFF TEARS INCREASES STEADILY AFTER THE FIFTH DECADE OF LIFE. USING ULTRASOUND EVALUATION, TEMPELHOF ET AL. STUDIED 411 ASYMPTOMATIC PATIENTS AND FOUND TEAR RATES OF 23.4% OVERALL AND 38% IN PATIENTS OLDER THAN 70.

24. LOSS OF CONTINUITY OF THE ROTATOR CUFF CAN BE DESCRIBED IN SEVERAL WAYS, INCLUDING ACUTE AND CHRONIC, PARTIAL OR FULL THICKNESS, AND TRAUMATIC OR DEGENERATIVE.

25. FULL-THICKNESS ROTATOR CUFF TEARS ALSO ARE CLASSIFIED BASED ON THEIR SIZE POPULARIZED BY COFIELD ET AL., IS BASED ON THE LARGEST DIMENSION OF THE TEAR: SMALL TEARS MEASURE < 1 CM; MEDIUM TEARS, 1CM TO 3 CM; LARGE TEARS, 3CM TO 5 CM; AND MASSIVE TEARS, < 5 CM.

26. WITH RESPECT TO PARTIAL-THICKNESS TEARS, ELLMAN PRESENTED A CLASSIFICATION WITH DESCRIPTIONS OF LOCATION – ARTICULAR, BURSAL, AND INTERSTITIAL. GRADES- DEPTH OF TEARS GRADE 1, TEARS- <3 MM DEEP; GRADE 2, TEARS- 3 TO 6 MM DEEP; GRADE 3, TEARS- >6 MM DEEP.

27. ACROMIOCLAVICULAR JOINT SPRAINS

28. AC JOINT SPRAINS ACCOUNT FOR ONLY 9% OF ALL SHOULDER INJURIES, ARE MOST FREQUENT IN MALES, IN THEIR THIRD DECADE OF LIFE, AND ARE USUALLY PARTIAL RATHER THAN COMPLETE SPRAINS. MOST INJURIES OCCUR AS A RESULT OF DIRECT TRAUMA FROM A FALL OR BLOW TO THE ACROMION.

29. ROCKWOOD CLASSIFIED AC JOINT SPRAINS INTO SIX TYPES - TYPE 1- SPRAINS INVOLVE A MILD INJURY TO THE AC LIGAMENTS, AND RADIOLOGIC EVALUATION IS NORMAL. TYPE 2- INJURIES INVOLVE THE COMPLETE DISRUPTION OF THE AC LIGAMENTS BUT WITH INTACT CORACO- -CLAVICULAR LIGAMENTS. RADIOGRAPHS MIGHT DEMONSTRATE CLAVICULAR ELEVATION RELATIVE TO THE ACROMION BUT LESS THAN 25% OF DISPLACEMENT.

30. TYPE 3- SPRAINS RESULT IN THE COMPLETE DISRUPTION OF THE AC AND CC LIGAMENTS, BUT THE DELTOTRAPEZIAL FASCIA REMAINS INTACT. RADIOGRAPHS REVEAL A 25% TO 100% INCREASE IN THE CORACOCLAVICULAR INTERSPACE RELATIVE TO THE NORMAL SHOULDER. TYPE 4- TYPE 3 WITH POSTERIOR DISPLACEMENT OF THE DISTAL CLAVICLE INTO THE TRAPEZIUS MUSCLE.

31. TYPE 5 SPRAINS- TYPE 3 WITH A RUPTURE OF THE DELTOTRAPEZIAL FASCIA. TYPE 6 SPRAINS- TYPE 5, WITH DISPLACEMENT OF THE DISTAL CLAVICLE BELOW THE ACROMION OR THE CORACOID PROCESS

32. ROCKWOOD CLASSIFICATION OF AC JOINT SPRAIN

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