Download - Anatomy of Instability
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Anatomy of G-H Joint
Stability & Instability
Glenohumeral jointCapsule/Ligaments/Glenoid
Instability/Impingement/RC tears
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Components of Stability
Concept: Considerable individual
variations in capsuloligamentous
anatomy, inherent shoulder laxityLaxity: Asymptomatic passive translation
of the humeral head on the glenoid
Instability: Pathologic condition manifest
as pain in association with excessive G!
movement"
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Articular Surface
GeometryGlenoid surface issmall articular surfacearea, #oll$%pin$%lide
important!umeral head toglenoid &:'
Golf ball sitting on a tee
%hape of the articularsurfaces altered byvarying thic(ness oflabrum
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Glenoid Labrum
)ibrocartilaginousstructure
Attachment superior
glenoid rim loose goodmobility
Inferior attachment firmpoor mobility
*loc(s humeral head
translations
Increased area ofarticulation +mm sup$infmm ant$post
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Suction Cup - Matsen
G! -oint compressiveforce of the head of thehumerus into the soc(etexpels the synovial fluid tocreate a suction thatresists distraction"
.egative Interarticularpressure is produced bythe limited volume of fluid
Compressive loadproduced by dynamicaction of musclecontraction
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Shoulder Capsule
Large, looseredundant for large#/0
1ariable thic(ness oflayers with discretethic(ening 2 capsularligaments
Anterior glenohumeralligaments include:%uperior$ 0iddle$Inferior
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G-H Ligaments
Coracohumeral ligament isthe strongest supportingligament
Portions of theCoracohumeral ligamentform a tunnel for thebiceps tendon
Portion of the #otator CuffInterval
%uperior G! ligament andthe coracohumeral limitsexternal rotation andabduction of the humerus
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Anterior G-H Ligaments
%uperior glenohumeral
ligament forms the anterior
cover around the long
head of the biceps and partof #CI
0iddle glenohumeral
ligament blends with
portions of the
subscapularis tendon and
is taut at 34 abd, '54
extension and external
rotation Anterior stability
between 34 and 654
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Inferior glenohumeral
Hammock like
structure with
attachments to theanterior labrum
Most important
stabilizer against
anterior ineriordislocation
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otator Cuff I ter!al
#CI region of the shoulder plays a role in
the pathomechanics and intervention of
patients with shoulder instabilities"Anteriorsuperior aspect of the shoulder
7efects are associated with large sulcus
sign combined with anterior instability
!arryman +8, #owe 9', *% defects in
the #CI significant factor in instability
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otator Cuff Inter!al
*ordered by thesupraspinatus and
subscapularisCapsular tissuecovers it andreinforced by the
coracohumeral lig"; the deepestsegment of the%GL
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Isolated Closure of CI "efects
for Shoulder Instability)ield,
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ole of G-H Capsular
Ligaments Int & #$t rotation*ranch et al" Am %ports 0ed +
%ix Cadaveric shoulders
Increased flexibility of the anterior capsuleis most effected by external #ot
Increased flexibility of the posterior
capsule is most effected by internal #ot"*oth share in limiting rotation at a number
of positions
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Guanche et al% Am J Sports
Med% '%ynergistic action of the capsule andshoulder muscles
%timulation of the Anterior and inferioraxillary articular nerves $ 4licited 40Gactivity of the
*iceps, %ubscapularis,
%upraspinatus, and InfraspinatusPosterior axillary nerve > 40G activity ofthe 7eltoid
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"ynamic Stability of the G-H
(oint )ia * mechanisms'" oint compression 2 #C and
biceps increases the conforming fit
of the humeral head into glenoid $%uction cup
8" Coordinated contraction of the #C
muscles > )orce couple control thetranslations of the humeral head
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"ynamic Stability of G-H
&" %ynergistic action of capsular
mechanoreceptors and the #C
muscles Guanche3" Glenohumeral oint and
%capulothoracic must function in a
coordinated manner" %table baseallows glenoid to ad-ust to changing
arm positions"
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otator Cuff +athology
Classification:
A" Primary Compressive 7isease
*" %econdary Compressive 7isease
C" ?ensile in-ury
7" 0acrotrauma4" Anterior and Posterior Impingement
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, Secondary Compressi!e
"isease .nderlying Instability of
G-H Jt%
Budoff, Nirschl et al JBJS 1998 Debridement of
partial-thickness tears C !ithout acromioplast"#
%upraspinatus is small and relatively wea(susceptible to overuse and trauma
4ccentric overload wea(ens
musculotendinous rotator cuff unitEnable to oppose superior migration
causing secondary impingement"
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+athological Changes
7eltoid retainsstrength longer than#C loss of depressor
effect on humeral hd"7uring elevation
#eactive anddegenerative osseouschanges$ /steophytic
spurring causing awea(ened cuff torupture resulting fromimpingement
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/ype III acromion /endinosis
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Acromioplasty
%urgery results most predictable forpain relief$less for increased strength
7isrupts periosteum and corticalbone of acromion, predisposes toextensive scar
%ubacromial decompressionpartialthic(ness tears 2 relief from pain dueto Postop rest and denervation
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C,/ensile 1!erload
#epetitive intrinsictension overload" !eavyrepetitive eccentric forcesincurred by the posterior #C
during deceleration and followthru of overhead sport activitiescan lead to tendon failure"
Pathologic changesdegenerative process densefibroblasts and disorganiFedcollagen 2 absence of
inflammatory cells)orce '5+5. to the #Cduring arm decelerationphase of throwing
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",Macotraumatic /endon 0ailure
%ingle event that create
forces greater than the
tendon can tolerate
)ull thic(ness tears of the#C with bony avulsions of
the greater tuberosity
Classification:
Partial thic(ness %uperior
surface$*ursal impingeEndersurface tensile strength
less
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#, Internal Impingement
$mpin%ement of deep surface of the subscap tendon
and the reflection pulle" on the ant&sup %lenoid rim:'erber et al J Sh&(lbo! Sur% )***#
Increased internal rotation with '55 deg )lexionthe lesser tuberosity and biceps tendon are
brought closer to the ant$sup glenoid rim and the
superior G! lig becomes lax"
At +5 deg flexion and internal rotation the deepsurface of the subscap is impinging against the
glenoid rim
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+osterior G-H pain in o!erhead
thro2ing athletes
Superior Glenoid Impingement Jobe3
Clin 1rtho 454xternal rotation +5 deg"
Abduction and horiFontal
extension early part of the
acceleration phase of
overhead throwingBImpingement of inner fibers
of the #C ; post sup" labrum
between the grt" tub and
post"sup glenoid
%econdary to lac( ofresistance from the
subscapularis causing
angulation of the humeral
head instead of translation
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Scapula Asymmetry
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Loehr & .hthoff 675
cada!eris C
!0ost degenerative tears originated onarticular side supraspinatus near insertion
Poor blood supplyunable to repair itself Pain develops if the degeneration of tissue
becomes inflamed
.o evidence that full thic(ness tear heals
%mall tears usually get larger Pain not associated to tear siFe$ strength is
related to siFe of tear
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+oor lood Supply
Supraspinatus"pa#ue dye into micro blood $essels
%rm in &'( abd %rm in adduction
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otator Cuff +artial /hic8ness
/ear ursal SurfaceInternal rotation and
le)ion o the sh*
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+atient +rognostic 0actors
Poor outcomes associated with:
'" ?ear greater than ' cm
8" !istory of symptoms greater
than one year
&" %ignificant functional
impairment
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Surgical epair !s ehab
)altow et al Prospective patient
study surgery vs exercise
69D of the surgical patients
66D of the exercise patients were
successful )$E 6 mo" 2 8"6 years
8D of the exercise group and 5D of
the placebo group had surgery
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1pen C epair !s Arthroscopic
"ebridement and "ecompression*ur(art /rthop Clin .orth Am '++&
8 patients 7ebridement and
7ecompression&5 mo )$E 2 95D pts" Good or excellentresults
0ontgomery %h 4lbow %urg '++3
9 patients )ull thic(ness #C tears8 year )$E open repair superior resultsas compared to arthroscopic group
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Impingement Syndrome
/reatment approachBan% + De"le ' Comparsion of super.ised
e/ercise !ith !ithout manual 0 for patients !ith
shoulder impin%ement s"ndrome J2S0 )***
.>8 8x$w( for & wee(s
*oth groups had the same exercise regime
0anual therapy group 0aitlandB %uperior to
exercise group only
0anual therapy group had significant increase in
strength, #/0, and decreased pain
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Scapular 9i ematics,
Stre gthe i g & Stretchi g
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/reatment Approach to
C /ears#educe pain andrestore scapulamobility andstrength
#estoration of G! -oint #/?A?I/.,arthro(inematics
Increase strengthand balance oflocal muscles
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Scapula Mobili:ation
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Scapula otator - #$ercises
7ec(er et al A%0 '+++
7ynamic !ug greatest
40G activity of
%erratus anterior
Lear ; Gross /%P? +9
Increase 40G for
serratus and upper
traps with pushup
with a plus and
elevation of the feet
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Scapula Strengthening
"ynamic Hug
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Case +resentation
Impingement %yndrome
!istory of thyroid resection
secondary to cancer of the thyroidEnable to palpatesternocleidomastoid, Anterior
scalene)orward head posture 2 Poorscapula rotator strength
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efore After
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efore After
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Scapula otator ;ea8ness
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#$ercises
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Case st d 0ootball +la er
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Case study 0ootball +layer
Impingement "iagnosis
efore After
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Strength /raining
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Summary
Anatomical factors stability and instabilityeg" Central position of humerus on glenoid
7ynamic stability importance of the rotatorcuff and scapula rotators
#otator Cuff 7isease is results frominstability, impingement, #C tear
0uscle activity can cause instability andcompressive force to the -oint" Improperexercise may cause shoulder dysfunction