REFERRED PAIN AND NERVE INJURY
Common Sources of
Referred Pain in the Shoulder Region
Cervical Spine
Vertebral joints between C3 and C4 or between C4 and
C5
Nerve roots C4 or C5
Referred Pain from Related Tissues
Dermatome C4 is over the trapezius to the tip of the
shoulder.
Dermatome C5 is over the deltoid region and lateral
arm.
Diaphragm: pain perceived in the upper trapezius
region.
Heart: pain perceived in the axilla and left pectoral
region.
Gallbladder irritation: pain perceived at the tip of
shoulder
and posterior scapular region.
Nerve Disorders in the Shoulder Girdle Region
Brachial plexus in the thoracic outlet
Common
sites for compression are the scalene triangle, costoclavicular space and under
the coracoid process, and pectoralis minor muscle.
Suprascapular nerve in the suprascapular notch
This injury
occurs from direct compression or from nerve stretch, such as when carrying a
heavy book bag over the shoulder.
Radial nerve in the axilla
Compression
occurs from continual pressure, such as when leaning on axillary crutches.
MANAGEMENT OF SHOULDER DISORDERS AND SURGERIES
To make sound clinical decisions when managing patients with
shoulder disorders, it is necessary to understand the various pathologies,
surgical procedures, and associated precautions and to identify presenting
impairments, functional limitations, and possible disabilities.
JOINT HYPOMOBILITY:
NONOPERATIVE MANAGEMENT
Glenohumeral Joint
Restricted mobility of the glenohumeral joint may occur as a
result of pathology such as rheumatoid arthritis or osteoarthritis, from
prolonged immobilization, or from unknown causes (idiopathic frozen shoulder).
Associated impairments in mobility and muscle performance also occur in the
muscles and other connective tissues in the area
Traumatic arthritis
This disorder occurs in response to a fall or blow to the shoulder or to microtrauma from faulty mechanics or overuse.
Postimmobilization arthritis or stiff shoulder
This
disorder occurs as a result of lack of movement or secondary effects from
conditions such as heart disease, stroke, or diabetes mellitus.
Idiopathic frozen shoulder
This
disorder, which is also called adhesive capsulitis or periarthritis, is
characterized by the development of dense adhesions, capsular thickening, and
capsular restrictions, especially in the dependent folds of the capsule, rather
than arthritic changes in the cartilage and bone, as seen with rheumatoid
arthritis or osteoarthritis. The onset is insidious and usually occurs between
the ages of 40 and 60 years; there is no known cause (primary frozen shoulder),
although problems already mentioned in which there is a period of pain and or
restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma,
or immobilization, may lead to a frozen shoulder (secondary frozen shoulder).
With primary frozen shoulder, the pathogenesis may be a provoking chronic
inflammation in musculotendinous or synovial tissue such as the rotator cuff,
biceps tendon, or joint capsule. Consistent with this is a faulty posture and muscle
imbalance predisposing the suprahumeral space to impingement and overuse
syndromes.
Clinical Signs and Symptoms
Glenohumeral joint arthritis
The
following characteristics are associated with glenohumeral (GH) joint
pathologies that lead to hypomobility.
Acute phase
Pain and muscle guarding limit motion, usually external
rotation and abduction. Pain is frequently experienced radiating below the
elbow and may disturb sleep. Joint swelling is not detected owing to the depth
of the capsule, although tenderness can be elicited by palpating in the fornix
immediately below the edge of the acromion process between the attachments of
the anterior and middle deltoid.
Subacute phase
Capsular tightness
begins to develop. Limited motion is detected, consistent with a capsular pattern
(external rotation and abduction are most limited, and internal rotation and
flexion are least limited). Often, the patient feels pain as the end of the
limited range is reached. Joint-play testing reveals limited joint play. If the
patient can be treated as the acute condition begins to subside by gradually
increasing shoulder motion and activity, the complication of joint and soft
tissue contractures can usually be minimized.
Chronic phase
Progressive
restriction of the GH joint capsule magnifies the signs of limited motion in a
capsular pattern and decreased joint play. There is significant loss of function
with an inability to reach overhead, outward, or behind the back.
Idiopathic frozen shoulder
This
clinical entity follows a classic pattern*.
“Freezing.” Characterized by intense pain even at
rest and limitation of motion by 2 to 3 weeks after onset. These acute symptoms
may last 10 to 36 weeks.
“Frozen.” Characterized by pain only with movement, significant
adhesions, and limited GH motions, with substitute motions in the scapula.
Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles occurs.
This stage lasts 4 to 12 months.
“Thawing.” Characterized by no pain and no synovitis but
significant capsular restrictions from adhesions. This stage lasts 2 to 24
months or longer. Some patients never regain normal ROM
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