Shoulder Region: Dislocation, Separation and Rotator Cuff Tear

by Sheldon C. Yao, DO

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    00:01 The shoulder joint is suspect to many different potential causes for pain and injury.

    00:06 Again, due to its mobility, it could be injured in many different ways.

    00:10 Osteopathic diagnosis and treatment could help you with identifying the cause of the issue and also with helping your patients to recover from the injury.

    00:19 Shoulder dislocation occurs when the humeral head is displaced from the glenoid fossa.

    00:25 Most commonly, dislocation is anterior and inferior because of the weakness of the labrum and how the muscles are attached. So, the shoulder tends not to dislocate posteriorly.

    00:35 After dislocation, patients usually are holding their arm in a specific position of abduction and external rotation.

    00:42 Usually there's a drop off of the shoulder when you compare in observation.

    00:47 A special test that you could perform to confirm it is called the apprehension test.

    00:53 If someone presents with a shoulder dislocation, immediate reduction and immobilization is required.

    01:01 The reduction is required to put the shoulder back into place so that you don't compromise neurovascular flow to the rest of the arm.

    01:10 You want to provide analgesic pain.

    01:12 Then at times, you may need surgical repair for certain cases.

    01:16 Osteopathic manipulation could help accelerate recovery.

    01:21 After reduction or surgery, treatment of the shoulder with gentle technique could help with decreasing some of the pain and edema in the area.

    01:30 Then you want to strengthen and increase his range of motion after surgery to help prevent frozen shoulder from occurring.

    01:37 The apprehension test could be used to evaluate for any sort of instability of the shoulder to dislocate.

    01:44 If the patient has a dislocated shoulder and it's extremely obvious this would not be something that you would do.

    01:50 So, if someone has a suspected shoulder instability where they said that their shoulder really hurts and it felt like it kind of popped out and popped in, you could kind of test for the integrity of the joint by trying to place them into a position and seeing if they elicit a response.

    02:08 So, how is it performed? Your physician will abduct and externally rotate the arm to about 90 degrees.

    02:15 Then you're going to apply an anterior pressure on the humerus.

    02:19 So, as you apply that anterior pressure on the humerus, if the shoulder is unstable, then the patient is going to have pain and appear apprehensive, thus the name of the test.

    02:28 So a positive test is if the patient has pain or apprehension due to the force on the shoulder for the patient would feel like he is potentially dislocating the shoulder.

    02:41 Another potential issue with shoulder pain is shoulder separations.

    02:46 This is usually due to some sort of traumatic force to the shoulder joint itself, some sort of blow or pull that separates the clavicle at the acromioclavicular space.

    02:58 Sometimes you can have a shoulder separation at the sternoclavicular ligament but a lot of times that is more rare.

    03:05 Usually, you could have a partial tear, or sometimes it could be a sprain, or in the case of this image there's a complete tear because of the distance.

    03:14 You can usually identify this via X-ray.

    03:18 Sometimes there could be some sort of fall on the point.

    03:21 Sometimes you might see this with sports injuries.

    03:24 So, it's important to rule this out with patients that have shoulder pain.

    03:28 Sometimes you might see a little bit more of a step off in the region when examining the AC joint.

    03:34 When you find this, you want to make sure that you support the shoulder.

    03:39 Usually, the shoulder will be immobilized if it's really severe.

    03:43 A complete separation surgery may be required at times.

    03:48 Osteopathic manipulative medicine can help with helping to decrease some of the swelling and pain in the area, decreasing some of the muscle spasms that may occur secondary to the shoulder injury, and also using some gentle techniques to try to mobilize the joint after it's healed to help restore motion in the area.

    04:11 Rotator cuff tears are common.

    04:13 Patients usually will complain about a soreness in the shoulder, pain with trying to abduct the shoulder.

    04:21 The most common tendon that's injured among the rotator cuff is the supraspinatus.

    04:27 It is really a lot more at risk based on the way that it traverses from the scapula to the glenoid and past the glenoid and onto attach on the humerus.

    04:39 The symptoms, usually patients are typically greater than 40 years old.

    04:45 There are certain special tests that you could perform to try to see if the tendon is still intact.

    04:52 The drop arm test and the empty can test both test for the stability and the intactness of that supraspinatus tendon.

    05:00 Usually, you could manage any sort of small tear inflammation with some anti-inflammatories, rest, and ice.

    05:09 However, if there is a full tear or severe injury, there might be a need for surgery.

    05:15 If it is infraspinatus or subscapularis tear then surgery is also required.

    05:20 Osteopathic management include gentle, indirect, passive techniques trying to free any sort of restrictions in the glenohumeral area, try to treat any sort of compensatory changes.

    05:32 So if someone has a rotator cuff tear, they're not going to want to move their arm especially with abduction.

    05:38 So, they’ll try to compensate and they'll start shrugging their shoulders to reach up higher, to grab things.

    05:43 So, there might be other muscles around the scapula itself, the thoracic cervical region, the back, that becomes more spasmed.

    05:51 We could try to treat specific points in the shoulder that might be tender with counterstrain technique, facilitate positional release.

    05:58 Myofascial release could help soften up some of the spasmed muscles in the area.

    06:02 So, the drop arm test is a test to test for rotator cuff tears.

    06:08 What you're going to ask is for the patient to slowly raise their arms up over their heads and touch the back of their hands together and slowly try to bring their arms down to their sides.

    06:18 If someone has a true rotator cuff tear, they're probably not going to be able to even bring their arm up over their head.

    06:24 But if they're bringing their arms down and then they can't smoothly and in a controlled fashion bring their arms down to their side, then that might indicate that the supraspinatus muscle has a tear in it because the supraspinatus muscle really performs abduction.

    06:40 So, as you slowly bring the arm down, The supraspinatus has to be intact in order to help support the abduction of the arm.

    06:50 The empty can test is another test to test for rotator cuff injury and tears.

    06:55 Here, you're going to have the patient turn their thumb down like they're emptying a can and then abduct their arm out to the side.

    07:03 With their arms to the side and their shoulder internally rotated, you're going to gently push down on their arms to see if they're able to resist your force.

    07:13 So, when you abduct and internally rotate your shoulder, what you're doing is you're compressing on that suprahumeral space where the supraspinatus tendon runs through.

    07:23 So, if a patient has a tear there or severe inflammation or injury, they're not going to be able to resist your force pushing their shoulder down.

    07:34 So, a positive test is if they cannot hold their arm up against your resistance.

    About the Lecture

    The lecture Shoulder Region: Dislocation, Separation and Rotator Cuff Tear by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Shoulder Region. It contains the following chapters:

    • Shoulder Dislocation
    • Shoulder Separation
    • Rotator Cuff Tear

    Included Quiz Questions

    1. Anterior and inferior
    2. Posterior and inferior
    3. Anterior and superior
    4. Posterior and lateral
    5. Posterior and superior
    1. Posterior
    2. Anterior
    3. Superior
    4. Coronal
    5. Lateral
    1. Abduction and external rotation
    2. Adduction and internal rotation
    3. Flexion and adduction
    4. Extension and adduction
    1. Surgery
    2. Waiting for spontaneous resolution
    3. NSAID
    4. Rest
    5. No treatment

    Author of lecture Shoulder Region: Dislocation, Separation and Rotator Cuff Tear

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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