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Advanced Clinical Pathology: The Shoulder (2 CE Hours)

This course is approved by the Texas Department of State Health Services DSHS for Continuing Education for Massage Therapists CE0009 and by the NCBTMB for Nationally Certified Massage Therapists for 2 CE Hours.

This informational article provides advanced study in clinical pathology of the shoulder. Pictures are provided to point out pathologies and related anatomy. Guidelines are given for the practical application of massage, where appropriate. Techniques are not presented in this informational course. 

Learning Objectives: After reading this course, you will...

  1. be able to list the anatomical structures of the shoulder girdle.
  2. be able to describe the pathologies associated with the shoulder joint and shoulder girdle.
  3. be able to list and describe the types of Superior Labral (SLAP) injuries.
  4. be able to expain how Massage Therapy can assist in healing rotator cuff problems.
  5. be able to describe the stages of shoulder impingement.
  6. be able to describe the factors that contribute to bony supraspinatus outlet compromise.
  7. be able to explain the difference between tendinitis and tenosynovitis.

Introduction to Advanced Clinical Pathology of the Shoulder Girdle

There are many pathologies associated with the shoulder, some of traumatic etiology and some that evolve out of repetitive mechanical stress. While many of these pathologies are out of the realm of treatment by the Massage Therapist, they can benefit by understanding common pathologies associated with the shoulder complex to educate themselves and their clients. Where applicable, we have given applied massage therapy information that the Massage Therapist will find useful.

Clavicular Fractures
The clavicle can be fractured by direct or indirect violence, the fracture typically at the junction of lateral and middle thirds.  The weight of the arm drags the lateral fragment inferiorly.

Acromioclavicular Joint Disease and Impingement
Arthrosis of the acromioclavicular joint, including callus and osteophytes, can contribute to impingement.  The acromioclavicular joint may encroach on the supraspinatus outlet and cause an extrinsic effect on the bursal surface of the musculotendinous junction of the supraspinatus.  MR is more accurate than conventional radiography in demonstrating the morphology and degree of AC joint enlargement and its relationship to soft-tissue structures under the coracoacromial arch (the rotator cuff).

Sternoclavicular Dislocation
Dislocations of the sternoclavicular joint are relatively rare and often difficult to diagnose from fractures due to plain imaging techniques. Posterior dislocations are less common than anterior and may involve associated damage to posterior structures either at the time of injury or during surgery to reduce the dislocation.

Suprascapular Nerve Entrapment
The suprascapular nerve is located in the supraspinous or spinoglenoid notch, at the superior border of the supraspinous fossa.  In this location the suprascapular nerve may be compressed by a ganglion or entrapped, secondary to thickening of the suprascapular ligament. 

Corocoid process of the Scapula
The origin of the coracoid is superior and medial to the glenoid on the scapular neck, and the tip of the coracoid projects anterior and lateral to the glenoid.  The coracoid is an important surgical landmark because neurovascular structures travel along its inferomedial surface. 

Acromion process of the Scapula
The acromion is classified as one of three types, depending on its morphology.  A type 1 acromion has a flat or straight undersurface with a high angle of inclination.  A type 2 acromion has a curved arc and decreased angle of inclination.  A type 3 acromion is hooked anteriorly, with a decreased angle of inclination.  The angle of inclination is formed by the intersection of a line drawn from the posteroinferior aspect of the acromion to the anterior margin of the acromion with a line formed by the posteroinferior aspect of the acromion and the inferior tip of the coracoid process. 

At the lateral angle of the scapula is the glenoid cavity (glenoid fossa) with its supra- and infraglenoid tuberosities.  The glenoid version angle varies, and may contribute to instability patterns of the shoulder.

Acromioclavicular Separations
There are three grades of AC separations: grade 1 is a sprain or incomplete tear of the AC joint capsule, grade 2 is a complete tear of the AC joint capsule with intact coracoclavicular ligaments, and grade 3 involves disruption of both the AC joint capsule and the coracoclavicular ligaments.  Widening of the AC joint space to 1.0 to 1.5 cm and a 25% to 50% increase in coracoclavicular distance is associated with tearing of the AC joint capsule and sprain of the coracoclavicular ligament.  Widening of the AC joint to 1.5 cm or a 50% increase in the coracoclavicular distance correlates with coracoclavicular ligament disruption.

Glenohumeral Arthritis
Degenerative osteoarthritis of the glenohumeral joint is relatively common.  It is characterized by cartilage-space narrowing, hypertrophic bone formation, subchondral cysts, and associated soft-tissue abnormalities of the rotator cuff.  In rheumatoid disease, unlike osteoarthritis, joint space narrowing is more uniform and symmetric, without osteophytosis.  Rheumatoid erosions occur at the margins of the articular cartilage, including the greater tuberosity.

Avascular Necrosis (AVN)
Avascular necrosis, death of bone due to decreased blood flow, of the humeral head can usually be differentiated from osteoarthritis on MR scans by the restriction of subchondral low signal intensity ischemia to the humerus, without associated glenoid involvement (i.e., sclerosis).  Avascular necrosis of the humeral head is associated with trauma, steroid use, sickle-cell disease, and alcoholism.

Intertubercular (Bicipital) Groove
A decrease in the height of the medial wall of the lesser tuberosity and the presence of a supratubercular ridge of bone projecting from the superolateral aspect of the lesser tuberosity may predispose to instability of the biceps tendon within the intertubercular (bicipital) groove, but dislocation or subluxation of the biceps tendon is extremely rare in the absence of a massive rotator cuff tear.

Humeral Head Changes
Degenerative cysts and sclerosis of the greater tuberosity can be seen in on MR scans in shoulder impingement.  Squaring and sclerosis of the greater tuberosity are best seen on coronal and sagittal oblique images.  Glenohumeral joint degeneration and rotator cuff tears represent the endstage in a spectrum of impingement.  A decrease in the acromiohumeral distance is also a finding in rotator cuff disease and advanced impingement, as is rounding of the greater tuberosity, often associated with corresponding changes of bone erosion or sclerosis on the inferior acromial surface.

Fractures of the Proximal Humerus
Neer classifies upper humeral fractures into four parts: (1) those involving the anatomic neck of the humerus, (2) those involving the greater tuberosity, (3) those involving the lesser tuberosity, and (4) those involving the shaft or surgical neck of the humerus. 

A one-part fracture has either no displacement or angulation of any of the segments, or displacement and angulation are minimal.  A two-part fracture involves displacement of one segment.  A three-part fracture involves displacement of two segments with an associated unimpacted surgical neck fracture with rotatory displacement.  A four-part fracture is characterized by displacement of all four segments.  Displacement is defined by fracture segment displacement of greater than 1 cm or angulation of more than 45º.

This classification is used at surgery and often applied to plain radiographs.

Clinically, there are two important issues: (1) risk of AVN, and (2) even minor dislocation is not tolerated.

 

 

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