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Anterolateral Impingement

supraspinatus mm, subacromial bursa

Anteromedial Impingement

subscapularis mm

Posterolateral Impingement

posterior labrum, infraspinatus, teres minor

Fall on outstretched arm

Clavicle fx; posterior dislocation; biceps, suprapinatus, or labral tear

Land on top of shoulder

AC separation, distal clavicle Fx

Arm abducted & extended at impact

Anterior dislocation

GH locks & "clicks" back in place

Labral tear

Worse with lifting weights and/or heavy objects

Osteolysis of the distal clavicle, labral tear

Overhead positions

Impingement syndrome
Biceps, supraspinatus, bursa

Is then neck & shoulder pain timing similar

Osteoarthritis (DJD), myofascial pain syndrome (MFPS)

Associated neck pain with trauma

Cervical sprain/strain, burner, brachial plexus injury

More stiffness than pain

Unreduced GH dislocation

Did the stiffness get worse after a few weeks of pain in shoulder

Adhesive capsulitis

Concurrent pain in other joints

Rheumatoid arthritis, Ankylosing spondylitis, Pseudogout (CPPD,HADD), DJD

Visceral complaints same time as the shoulder complaint: GI complaints

Referred pain from gallbladder

Visceral complaints same time as the shoulder complaint: Pulmonary complaints

Infection, tumor, etc.

Visceral complaints same time as the shoulder complaint: Cardiac complaints

Myocardial infarction

Location: Anterior, Traumatic

Fracture, GH dislocation, subacromial bursitis, capsular sprain, strain/rupture of the long head of biceps, labral tear

Location: Anterior, Non-traumatic or overuse

Impingement syndrome, subcoracoid impingment, biceps tendinitis, subacromial bursitis, subscapularis tendinitis, subluxation

Location: Lateral, Traumatic

Contusion, suprapinatus sprain/rupture

Location: Lateral, Non-traumatic or overuse

Impingement syndrome, deltoid strain, suprapinatus strain/rupture, visceral referral

Location: Superior, Traumatic

AC separation, distal clavicle fracture

Location: Superior, Non-traumatic or overuse

Osteoarthritis (DJD) affecting the AC joint, osteolysis of the distal clavicle

Location: Posterior, Traumatic

Scapular fracture, posterior dislocation

Non-traumatic or overuse

Posterior impingement, infraspinatus/teres minor mm strain/tendinitis, posterior deltoid/triceps mm strain

Trauma and pain in all ranges


Pain at midrange of abduction (70 -110°)

Impingement syndrome

Restriction of active ROM only


Restriction of active & passive ROM

Capsule, bone

Inability to hold/lower the abducted arm

Rotator cuff

When combined, found to be as sensitive as MRI for labral tears

Crank test
Load and shift test
Apprehension test(s)

Empty can test

Jobe's test

Biceps tendon


AC separation/sprain

Sudden pain from fall on outstretched arm or fall on top of shoulder, lifting heavy objects

Type 1 AC separation

Some tearing, no instability
Conservative care

Type 2 AC separation

Rupture of AC lig, unstable
Conservative care

Type 3 AC separation

Rupture of AC & coracoclavicular ligs (conoid and trapezoid), unstable
Conservative care with Kenny Howard sling (2-3 weeks) then rehab (if not recovered, then send for surgical consult)

Type 4 AC seperation

Posterior displacement of distal clavicle

Type 5 AC separation

Inferior acromion

Type 6 AC separation

Conjoined biceps and coracobrachialis tendon

Adhesive Capsulitis

Pain in external rotation and abduction
Usually over 40 y.o.
Females > Males
History of pain lasting for weeks > gradual stiffening of the shoulder as the pain diminishes
Patients note a dramatic decrease in shoulder ROM

Adhesive Capsulitis associated conditions

Cervical spondylosis, hypothyroidism, and diabetes are related conditions


Insidious onset of achy pain and loss of ROM
Loss of active and passive ROM
Should be considered in all elderly or postraumatic patients

Traumatic Instability

Pain or weakness with overhead activity or in apprehension position
History of shoulder dislocation


Labral avulsion from the glenoid rim with capsular stripping from the scapular neck


Labral avulsion with bone from the anterior glenoid rim and capsular stripping from the medial scapular neck

Bankart type 1

0.5 cm avulsion

Bankart type 2

1.0 cm avulsion

Bankart type 3

1.5 cm avulsion of capsule

Bankart type 4

fx of glenoid rim

Chronic Labral Tears

Pain and clicking with rotational movements, but ROM is usually full
History of trauma or instability or laxity

Non-Traumatic Instability

"Born loose", symptomatic due to poor biomechanics of the shoulder coupled with overuse or trauma
Passive care directed at symptoms, rehab focusing on shoulder mechanics and strength
Avoid positions that stretch the capsule

T.U.B.S. ("Torn Loose")

Bankart Lesion
Surgery should be considered


Multidirectional Instability
Bilateral Laxity
Rehabilitation Helps
Inferior Capsule Tightened
Surgical tightening of rotator interval
The rotator interval is a triangular portion of the shoulder capsule which lies between the supraspinatus and subscapularis tendons

Impingement Syndrome: Humeral tuberosity


Painful arc 45~120

GH impingement

Painful arc 170~180

AC pathology

Rotator Cuff Tear

History of chronic or acute trauma
Complain of pain with overhead activities or unable to raise the arm
Supraspinatus: Most commonly torn tendon
Signs like impingement, may have weakness

Biceps tendon tear

Bunching up of the muscle
(+) Transverse humeral ligament test
Weak and painful = partial tear
Weak and painless = full tear (with or without neurologic damage)
Approx 50% of all ruptures occur thru the tendon of the long head > Some strength will remain

Proximal Biceps Tendon Rupture (Long Head)

From resisted forced flexion (eccentric)
May be secondary to repetitive cortisone injections
Palpable and visible defect with "popeye" muscle
Weakness on supination (Yergason's)
Surgery for young; conservative care for elderly

"SLAP" Lesion

Detachment lesion of the superior aspect of the glenoid labrum, which serves as the insertion of the long head of the biceps
A traction injury, such as catching oneself falling, is a common cause
A fall on the outstretched hand ("F.O.O.S.H."), or repetitive activities (pitching) may predispose to this injury
Normal Anatomy: in one half of patients, the biceps attaches to the supraglenoid tubercle (other half: biceps attaches to the superior labrum)
Rotator cuff pathology is present in 40% of patients with "SLAP" lesions
Pain with overhead activities mimicking impingement syndrome (be careful)*

Type I "SLAP"

Fraying and degeneration of the superior labrum (with firm attachment to the glenoid), normal biceps; usually degenerative in nature

Type II "SLAP"

Detachment of superior labrum and biceps insertion from the supra-glenoid tubercle (this is the most common type of SLAP lesion; may resemble a normal variant)


"Bucket handle-type" tear (biceps anchor is intact)

Type IV "SLAP"

Vertical tear of the superior labrum, which extends into biceps; may be treated w/ biceps tenodesis if more than 50% of the tendon is involved

Tendinitis & Bursitis

Usually severe pain that is worse with most ROM (insidious, related to overuse, or result of a trauma)
Distinct location of palpatory tenderness
Treat as any other tendinitis/bursitis
Sling for support, but do not leave it on for extended periods of time, and encourage shoulder exercises to tolerance

Subacromial Bursa

A large synovial membrane which is adherent to undersurface of coracoacromial ligament, acromion, & deltoid laterally (floor is adherent to rotator cuff & greater tuberosity)
Envelops proximal humerus (facilitates gliding of proximal humerus under coracoacromial arch)

Calcific Tendinitis

Usually not seen until the 4th decade
Diabetic patients are more likely to develop asymptomatic rotator cuff calcium deposits
> 30% of insulin-dependent diabetics had tendon calcification (< 10% of non-diabetics have this lesion)

Osteolysis of the Clavicle

Diffuse pain felt at the distal clavicle
Patient is often a young, serious weightlifter (as opposed to an old, casual weightlifter?)
Complaints of pain with bench pressing, overhead pressing, and/or dips
Cause unknown (usually related to AC trauma resulting in resorption of the distal clavicle)
Pain with ABD >90, ortho exam is often unremarkable
AC spot view (widening of joint space, subchondral defects)
Ergonomically modify to narrow grip, avoid dips
Surgery= acromioplasty

Little Leaguer's Shoulder

Proximal humerus pain in an adolescent that occurs primarily with throwing hard
Salter Harris Type I (due to rotational stress on the growth plate)
Palpable tenderness
Pain on resisted external rotation and supraspinatous test
Diagnosed by x-ray—widened humeral physis

Suprascapular nerve

Sensory: Supraspinatous area (Supraclavicular C3~C4), (Infra = Sup scap)
Supraspinatus/infraspinatous mm atrophy
Secondary to suprascapular notch trauma

Axillary (circumflex) nerve

Sensory: Lateral deltoid area (C5~C6)
Deltoid/teres minor mm atrophy
Secondary to anterior humeral dislocation

Radial nerve

Sensory: Dorsal surface of hand (Radial: C5~T1, Radial superficial: C6~C8)
Elbow/wrist extensor mm atrophy
Secondary to humerus fracture

Musculocutaneous nerve

Sensory: Lateral forearm (C5~C7)
Elbow flexor mm atrophy (biceps)
Secondary to forced elbow hyperextension or repetitive pronation

Long Thoracic N

Serratus anterior mm atrophy ("scapular winging")

Spinal Accessory N

Trapezius mm atrophy

Clavicle Fractures

usually middle third

Humerus Flap fracture

occurs in the great tubercle secondary to relocation of an anterior dislocation

Myositis Ossificans

Heterotopic bone formation secondary to trauma to sheath covering muscle or bone


Fracture is discovered
Ligament/tendon rupture is suspected
instability that would likely result in permanent disability
Non-reduced dislocation

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