MAMCOTS | Decoding the Shoulder: From Evolution to Clinical Mastery | Dr. P. S.Mamtora

Evolution from quadruped to biped involved changes in the shoulder girdle, from a deep acetabular-like fossa to a shallow glenoid cavity, and an opening of the shoulder girdle, which increased mobility at the cost of stability. Resultantly, the dynamic stabilizers of the shoulder - the rotator cuff muscles in the process of delivering stability are easily prone to injuries so is the shoulder joint prone to dislocation.

The 3 muscle groups, viz., the prime mover, steering group, and depressor group, work at different levels to produce movement at the shoulder joint. Comprehension of anatomy and the functional anatomy of the shoulder allows better clarity about the pathology involved. This patho-anatomic understanding will aid in knowing the clinical aspects of the pathology that shall guide towards the specific type of physiotherapy and exercises

The depressor muscles of the shoulder also need to be worked on during physiotherapy to achieve full range of motion at the shoulder.

Poor posture leads to shoulder protraction and resultant hyperkyphosis of the upper dorsal spine. This limits periscapular muscle function; therefore, it is imperative to achieve shoulder girdle retraction to enable full abduction through targeted exercises and physiotherapy.

Anatomical orientation of the shoulder complex: the ligaments and muscles that stabilise the humerus and scapula. Topics covered include the ligaments around the acromioclavicular and glenohumeral joints, the labrum and capsule of the shoulder joint, the rotator cuff muscles, biceps brachii, latissimus dorsi, pectoralis major, and the bursae around the shoulder joint.

An elaborate, systematic history-taking is imperative in determining the cause of the patient’s ailments. More often than not, the diagnosis is established from clinical history. Relevant questions to ask include: duration (consistent/intermittent), Origin, progression, location of pain, radiation, and relieving/aggravating modalities. Don’t miss asking about the joint above and the joint below.

Clinical examination begins with Inspection: posture, protraction of the shoulder girdle, prominent CD junction, muscle spasm. Palpation - confirmation of paraspinal spasm - which muscle, check for Range of motion if accompanied by pain or restriction, cervical neurological signs- motor and sensory. Also examine the shoulder joint and its range of motion, and check for rotator cuff impingement. Often, clinical examination establishes the working diagnosis.

Evaluate symptoms and make a patho-anatomical correlation. Analyse symptoms such as vertigo and tenderness at the Acromioclavicular joint, and link them to the pathology. Only after a thorough history and examination, look for the patient's reports to connect with the clinical findings. Ask for investigations - X-rays, MRI and if required blood investigations. The case ends successfully by reassuring and mentoring the patient on lifestyle changes, exercise, and appropriate physiotherapy.

Causes of acute-onset shoulder pain lie in Trauma (fracture, rotator cuff tears or dislocation); spontaneous-onset severe pain can be due to crystal /calcific induced tendinitis, infection or acute cervical radiculopathy. Chronic shoulder pain has a gradual progression beyond 4 weeks, with pathology such as rotator cuff injuries (repetitive stress), degenerative (glenohumeral/ acromioclavicular arthritis, tendinitis), infection, cervical spondylotic radiculopathy, inflammatory arthropathy or AVN of the humeral head. In cases of infection, it is imperative to obtain a histopathological study and culture before starting treatment. One of the D/D of frozen shoulder is AVN and glenohumeral arthritis.

In shoulder pain, also consider non-orthopaedic causes such as angina in left shoulder pain, phrenic nerve irritation, and Pancoast tumour, and vice versa. Left acute shoulder pain radiating to the arm could often be acute cervical radiculopathy. The hallmark of Cervical discogenic radiculopathy is the presence of radicular pain in the arm with or without neck pain, neurodeficit, transient relief from raising the arm over the head and possible restriction of cervical spine ROM. Shoulder pathology typically causes pain when raising the arm over the head.

Acute discogenic pain is often worse when lying down initially, but it improves over time in the horizontal position because the pressure on the disc, and hence the pressure on the nerve, decreases. However, acute shoulder pain, as in calcific rotator cuff tendinopathy, is not altered with change in position and is consistent due to the inflammatory pathology. However, non-inflammatory tendinitis may show a pain aggravation or amelioration pattern with respect to position, such as lying on the affected side.

The shoulder should be viewed from the anterior, posterior, and lateral views, as well as from the top, to detect protraction of the shoulder girdle. Inspect the muscles: trapezius, rhomboids, deltoid. Deltoid atrophy denotes chronic pathology. Obliteration of the delto-pectoral groove and loss of the deltoid curve suggest anterior shoulder dislocation. A prominent acromioclavicular joint is seen in AC joint osteoarthritis or AC joint disruption.

The range of motion at the shoulder should be assessed and assigned the appropriate degree, which indicates the extent of movement permitted. This scoring is important for follow-up evaluation to assess improvement. The range of motion that needs to be checked are - internal and external rotation, flexion and extension, true and total - both passive and active movements. Acute non-traumatic pathology like calcific tendinitis will allow gentle passive movement of the shoulder, whereas active ROM will be significantly restricted due to pain.

Check for tenderness; unilateral sternoclavicular prominence with tenderness suggests sternoclavicular pathology; the most common cause is monoarticular arthropathy of unknown origin; rule out Koch's. Suspect clavicle fracture when there is a history of trauma and tenting with tenderness, especially in children. A prominent, tender acromioclavicular joint and pain during abduction beyond 120 degrees qualify for AC joint pathology; with no history of trauma, this signifies AC joint synovitis/OA, which worsens with hyperuricemia. Subacromial tenderness is seen in subacromial bursitis and rotator cuff tendinopathies; pain on internal rotation denotes supraspinatus tendinopathy.

A positive Drop arm test indicates a rotator cuff tear; in the elderly, trivial trauma combined with underlying degeneration is the causative factor, and in the young, significant trauma is the causative factor. Passive ROM may be full; however, active ROM is often partial or painful. A positive test is pain during active mid-range movement and, when the arm is lowered under gravity with no effort from the depressor muscles, the arm drops; hence the Drop Arm Sign.

Pain and/or weakness during active resisted movement points to pathology of soft contractile tissues (muscles, tendons and attachments). Bicipital tenosynovitis - pain during active resisted flexion and supination of the forearm. Supraspinatus tendinitis: pain on resisted internal rotation and forward elevation. Similarly assess Infraspinatus. Tendinopathy will cause more pain; however, a tendon tear will lead to weakness with pain. Check for Impingement: pain at the subacromial region with forward flexion at 90 deg with the elbow flexed, and sudden internal rotation points to supraspinatus rotator cuff tendinitis.

The apprehension test is the only test that will be positive in recurrent dislocators. Method: Abduct the shoulder to 90 deg with the elbow at 90 deg flexion and externally rotate the shoulder; pain or apprehension indicates anterior shoulder instability. Look for atrophy of the supraspinatus and Infraspinatus fossa, which denotes Suprascapular nerve entrapment or neuropathy. A sublabral anteroposterior tear: Relax the patient's shoulder by placing your hand on the examiner's shoulder, stabilise the upper limb, and apply downward force; this generates pain due to stretching of the torn labrum.

Tendinopathy /tendinosis has no inflammatory component, often a degenerative background. Recommended physiotherapy includes eccentrically loaded exercises for that particular muscle or tendon. Tendinitis has an inflammatory component. The distinction between tendinopathy and tendinitis is not possible clinically and can be diagnosed only on MRI.

The Y view X-ray demonstrates abnormalities of the acromioclavicular joint, such as osteophytes in arthropathy or a raised humeral head, both of which can reduce the outlet or subacromial space. A raised humeral head could be due to supraspinatus dysfunction (tear/tendinopathy) with an overworking deltoid, which reduces the subacromial space and further worsens impingement. To depress the head of the humerus, strengthen the infraspinatus and subscapularis, thus counteracting the upward pull of the deltoid, which will in turn reduce the impingement.

Presentation of acute rotator cuff tendinitis (calcific): sudden, spontaneous, severe throbbing pain in the shoulder and/or arm, with inability to raise the arm. The D/D of rotator cuff tendinitis is cervical discogenic radiculopathy; in the former, cervical ROM is full, and there is no neurologic deficit. The calcific deposit could be uric acid or calcium crystals. Double Absorptiometry CT scan can pick up uric acid crystals as a green deposit. Management is rest in an immobiliser. Local ice and anti-inflammatory medicines.

Ledum Pal, Colchicum, and Calcarea Flour 6X are some of the Homoeopathic drugs for Acute calcific rotator cuff tendinitis, suggested by Dr Mamtora from his rich and vast experience. The management,, howeve,r, for any crystal (oxalate, calcium, CP,PD or uric aci-d) induced tendinitis remains the same. Calcific tendinitis deds an immediate mana,gment -resmedication;cines, negliwhich can lead to secondary frozen shoulder.

Illustration of Shoulder Immobilizer. A shoulder immobilizer and not an arm pouch sling is recommended for shoulder fracture, dislocation, acute calcific tendinitis, bursitis where a continuous immobilisation is a mandate for proper healing.

Understanding the patho-mechanics in rotator cuff tendinitis aids in deciding the physiotherapy approach and further management.

Pearls of wisdom shared by Dr Mamtora Sir, based on his vast clinical experience: Frozen shoulder is often seen in people who are anxious, have difficulty in 'letting go', and are unable to accept, adjust and adapt to a change in situation and circumstances. Interesting anecdotes on the vulnerable psyches of such people are explained.

The MRI of a Frozen Shoulder reveals edema of the inferior capsule with thickening which leads to restriction of abduction due to the tightness.

Clinical identification of an anteriorly dislocated shoulder - a lowered anterior axilary border, fullness of delto pectoral groove and inability to touch the opposite shouder with the affected arm. before trying closed reduction of dislocated shoulder rule out fracture. Closed reduction: Lying supine, ask the patient to relax for the muscles to become loose; apply consistent traction while performing a gentle external rotation. Confirm reduction by touching the opposite shoulder. Once reduction is achieved advice shoulder immobilizer.

A plain radiograph reveals the subluxed humeral head medially, overlying the glenoid in an anterior dislocation. An axillary view is obtained to diagnose posterior dislocation. Hill-Sachs lesion seen on the posterolateral aspect of the humerus is a compression fracture as a result of recurrent anterior shoulder dislocations. Treatment options are conservative (shoulder immobiliser for at least 6 weeks) or surgery (recommended in young athletes after the first episode).

Acromio-clavicular joint disruption a triad of prior injury, followed by AC jt tenderness and prominence and difficulty to raise arms completely. Illustration of SLAP tear where there is injury to the top of the labrum, SLAP stands for Superior Labral anterior- posterior tear. Sprengel shoulder, a rare congenital disorder where the scapula does not descend and is also abnormally attached to the spine.